- 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
- $852.62 / $860.74 / $954.25
| Professional | | $852.62 | $860.74 | $954.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.45 / $1,069.94 / $1,514.11
| Professional | | $909.45 | $1,069.94 | $1,514.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,347.57 / $1,675.68
| Professional | | $250.00 | $1,347.57 | $1,675.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $7,819.00 / $19,195.00
| Facility | | $5,074.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.97 / $1,157.06 / $1,819.19
| Professional | | $841.97 | $1,157.06 | $1,819.19 |