- 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
- $563.45 / $774.09 / $801.62
| Professional | | $563.45 | $774.09 | $801.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.62 / $841.91 / $1,390.13
| Professional | | $715.62 | $841.91 | $1,390.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $985.31 / $1,516.20
| Professional | | $300.00 | $985.31 | $1,516.20 |
- 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
- $536.71 / $768.16 / $1,568.66
| Professional | | $536.71 | $768.16 | $1,568.66 |