- 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
- $648.35 / $665.44 / $781.07
| Professional | | $648.35 | $665.44 | $781.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.61 / $741.89 / $1,160.72
| Professional | | $630.61 | $741.89 | $1,160.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $813.14 / $1,347.03
| Professional | | $150.00 | $813.14 | $1,347.03 |
- 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
- $533.66 / $850.03 / $1,309.26
| Professional | | $533.66 | $850.03 | $1,309.26 |