- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.36 / $1,128.88 / $1,397.45
| Professional | | $795.36 | $1,128.88 | $1,397.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.77 / $1,464.43 / $1,965.89
| Professional | | $1,244.77 | $1,464.43 | $1,965.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,607.25 / $2,474.61
| Professional | | $250.00 | $1,607.25 | $2,474.61 |
- 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
- $840.46 / $1,575.79 / $2,654.49
| Professional | | $840.46 | $1,575.79 | $2,654.49 |