- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,778.87 / $4,519.26 / $4,519.26
| Facility | | $2,778.87 | $4,519.26 | $4,519.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.96 / $391.18 / $1,148.63
| Professional | | $219.96 | $391.18 | $1,148.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.80 / $763.49 / $1,090.70
| Professional | | $235.80 | $763.49 | $1,090.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.54 / $470.02 / $1,834.44
| Professional | | $238.54 | $470.02 | $1,834.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.44 / $1,271.57 / $1,976.60
| Professional | | $851.44 | $1,271.57 | $1,976.60 |