- 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
- $846.69 / $864.26 / $1,126.79
| Professional | | $846.69 | $864.26 | $1,126.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.45 / $1,037.00 / $1,644.35
| Professional | | $881.45 | $1,037.00 | $1,644.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,129.83 / $1,740.01
| Professional | | $150.00 | $1,129.83 | $1,740.01 |
- 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
- $840.95 / $1,203.73 / $1,852.55
| Professional | | $840.95 | $1,203.73 | $1,852.55 |