- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.32 / $310.51 / $401.04
| Professional | | $209.32 | $310.51 | $401.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.72 / $374.14 / $503.31
| Professional | | $252.72 | $374.14 | $503.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,325.00 / $1,325.00 / $2,591.44
| Facility | | $1,325.00 | $1,325.00 | $2,591.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.41 / $428.85 / $765.83
| Professional | | $271.41 | $428.85 | $765.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $7,350.00
| Facility | | $2,569.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.73 / $442.38 / $762.17
| Professional | | $272.73 | $442.38 | $762.17 |