- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.65 / $597.36 / $795.37
| Professional | | $585.65 | $597.36 | $795.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.28 / $721.51 / $1,131.27
| Professional | | $613.28 | $721.51 | $1,131.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $789.75 / $1,197.99
| Professional | | $250.00 | $789.75 | $1,197.99 |
- 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
- $567.32 / $828.97 / $1,276.58
| Professional | | $567.32 | $828.97 | $1,276.58 |