- 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
- $932.03 / $952.86 / $1,271.39
| Professional | | $932.03 | $952.86 | $1,271.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.77 / $1,142.08 / $1,811.67
| Professional | | $970.77 | $1,142.08 | $1,811.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,244.39 / $1,915.23
| Professional | | $350.00 | $1,244.39 | $1,915.23 |
- 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
- $840.67 / $1,319.01 / $2,029.82
| Professional | | $840.67 | $1,319.01 | $2,029.82 |