- 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
- $880.20 / $898.77 / $1,204.33
| Professional | | $880.20 | $898.77 | $1,204.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.69 / $1,078.46 / $1,707.42
| Professional | | $916.69 | $1,078.46 | $1,707.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,175.61 / $1,817.02
| Professional | | $150.00 | $1,175.61 | $1,817.02 |
- 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
- $898.67 / $1,249.39 / $1,922.91
| Professional | | $898.67 | $1,249.39 | $1,922.91 |