- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.15 / $3,243.94 / $3,955.04
| Facility | | $2,424.15 | $3,243.94 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.64 / $786.63 / $1,034.05
| Professional | | $769.64 | $786.63 | $1,034.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.85 / $945.70 / $1,582.83
| Professional | | $803.85 | $945.70 | $1,582.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,032.88 / $1,614.79
| Professional | | $300.00 | $1,032.88 | $1,614.79 |
- 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
- $695.85 / $1,091.79 / $1,680.86
| Professional | | $695.85 | $1,091.79 | $1,680.86 |