- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $3,467.37
| Professional | | $977.24 | $1,318.26 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,348.96 / $2,187.76
| Professional | | $1,023.29 | $1,348.96 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,737.80 / $2,818.38
| Professional | | $151.36 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,698.24 / $2,884.03
| Professional | | $1,000.00 | $1,698.24 | $2,884.03 |