- 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
- $801.56 / $818.74 / $1,091.75
| Professional | | $801.56 | $818.74 | $1,091.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.72 / $983.20 / $1,554.47
| Professional | | $835.72 | $983.20 | $1,554.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,072.14 / $1,642.47
| Professional | | $150.00 | $1,072.14 | $1,642.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $4,086.00 / $9,622.00
| Facility | | $2,838.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.03 / $1,001.83 / $1,752.36
| Professional | | $816.03 | $1,001.83 | $1,752.36 |