- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.94 / $269.72 / $1,151.23
| Professional | | $117.94 | $269.72 | $1,151.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.11 / $727.72 / $1,225.03
| Professional | | $177.11 | $727.72 | $1,225.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $349.33 / $2,072.56
| Professional | | $180.00 | $349.33 | $2,072.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.00 / $2,384.00 / $5,510.00
| Facility | | $1,395.00 | $2,384.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.19 / $1,436.62 / $2,235.87
| Professional | | $875.19 | $1,436.62 | $2,235.87 |