- 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
- $723.94 / $743.29 / $1,014.13
| Professional | | $723.94 | $743.29 | $1,014.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.45 / $991.12 / $1,608.25
| Professional | | $842.45 | $991.12 | $1,608.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,187.60 / $1,712.65
| Professional | | $250.00 | $1,187.60 | $1,712.65 |
- 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
- $722.73 / $1,174.11 / $1,716.82
| Professional | | $722.73 | $1,174.11 | $1,716.82 |