- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.84 / $1,041.72 / $1,413.87
| Professional | | $1,021.84 | $1,041.72 | $1,413.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.17 / $1,253.14 / $2,019.07
| Professional | | $1,065.17 | $1,253.14 | $2,019.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,366.84 / $2,099.62
| Professional | | $350.00 | $1,366.84 | $2,099.62 |
- 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
- $923.33 / $1,340.30 / $1,996.96
| Professional | | $923.33 | $1,340.30 | $1,996.96 |