- 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
- $830.23 / $1,207.91 / $1,225.66
| Professional | | $830.23 | $1,207.91 | $1,225.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.99 / $1,269.40 / $2,111.17
| Professional | | $1,078.99 | $1,269.40 | $2,111.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,601.71 / $2,220.48
| Professional | | $250.00 | $1,601.71 | $2,220.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.00 / $4,086.00 / $9,622.00
| Facility | | $3,146.00 | $4,086.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.54 / $1,522.77 / $2,344.87
| Professional | | $970.54 | $1,522.77 | $2,344.87 |