- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,954.27 / $3,955.04 / $5,494.68
| Facility | | $2,954.27 | $3,955.04 | $5,494.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.60 / $699.71 / $917.62
| Professional | | $529.60 | $699.71 | $917.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.54 / $731.24 / $1,015.74
| Professional | | $621.54 | $731.24 | $1,015.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $751.78 / $1,141.69
| Professional | | $200.00 | $751.78 | $1,141.69 |
- 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
- $521.54 / $791.37 / $1,216.53
| Professional | | $521.54 | $791.37 | $1,216.53 |