- 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
- $793.43 / $879.33 / $1,032.51
| Professional | | $793.43 | $879.33 | $1,032.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.65 / $973.71 / $1,538.67
| Professional | | $827.65 | $973.71 | $1,538.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,062.03 / $1,661.03
| Professional | | $150.00 | $1,062.03 | $1,661.03 |
- 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
- $767.51 / $984.82 / $1,713.62
| Professional | | $767.51 | $984.82 | $1,713.62 |