- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.18 / $473.21 / $911.77
| Professional | | $263.18 | $473.21 | $911.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.56 / $516.39 / $813.20
| Professional | | $320.56 | $516.39 | $813.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $543.28 / $1,439.44
| Professional | | $250.00 | $543.28 | $1,439.44 |
- 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
- $598.37 / $993.65 / $2,131.84
| Professional | | $598.37 | $993.65 | $2,131.84 |