- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.34 / $2,504.54 / $5,371.96
| Facility | | $1,184.34 | $2,504.54 | $5,371.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.23 / $3,646.50 / $7,441.20
| Professional | | $255.23 | $3,646.50 | $7,441.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.00 / $851.00 / $1,316.00
| Professional | | $709.00 | $851.00 | $1,316.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.61 / $460.30 / $611.72
| Professional | | $277.61 | $460.30 | $611.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.89 / $466.23 / $967.58
| Professional | | $287.89 | $466.23 | $967.58 |