- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,897.79 / $8,511.38
| Facility | | $1,778.28 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $288.40 / $537.03
| Professional | | $208.93 | $288.40 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $537.03 / $724.44
| Professional | | $338.84 | $537.03 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $354.81 / $1,000.00
| Facility | | $234.42 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $2,691.53 / $2,691.53
| Professional | | $575.44 | $2,691.53 | $2,691.53 |