- 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
- $563.77 / $575.05 / $765.72
| Professional | | $563.77 | $575.05 | $765.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.04 / $695.35 / $1,087.44
| Professional | | $591.04 | $695.35 | $1,087.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $761.80 / $1,151.13
| Professional | | $150.00 | $761.80 | $1,151.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.50 / $762.94 / $1,046.33
| Professional | | $545.50 | $762.94 | $1,046.33 |