- 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
- $709.37 / $755.56 / $978.45
| Professional | | $709.37 | $755.56 | $978.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.13 / $875.45 / $1,387.20
| Professional | | $744.13 | $875.45 | $1,387.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,027.29 / $1,535.51
| Professional | | $300.00 | $1,027.29 | $1,535.51 |
- 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
- $575.10 / $889.73 / $1,462.67
| Professional | | $575.10 | $889.73 | $1,462.67 |