- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,466.84 / $10,232.93
| Facility | | $1,202.26 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,202.26 / $2,089.30
| Professional | | $512.86 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,737.80 / $1,737.80
| Professional | | $489.78 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,344.23 / $7,244.36
| Facility | | $1,288.25 | $2,344.23 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,398.83 / $3,388.44
| Professional | | $933.25 | $2,398.83 | $3,388.44 |