- 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
- $635.79 / $861.83 / $988.12
| Professional | | $635.79 | $861.83 | $988.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.11 / $960.13 / $1,540.62
| Professional | | $816.11 | $960.13 | $1,540.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,013.65 / $1,674.69
| Professional | | $300.00 | $1,013.65 | $1,674.69 |
- 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
- $674.06 / $1,160.83 / $1,781.80
| Professional | | $674.06 | $1,160.83 | $1,781.80 |