- 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
- $715.05 / $721.97 / $976.11
| Professional | | $715.05 | $721.97 | $976.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.93 / $881.09 / $1,429.05
| Professional | | $748.93 | $881.09 | $1,429.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,039.81 / $1,530.56
| Professional | | $300.00 | $1,039.81 | $1,530.56 |
- 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
- $681.51 / $918.54 / $1,473.40
| Professional | | $681.51 | $918.54 | $1,473.40 |