- 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
- $942.98 / $961.58 / $1,292.30
| Professional | | $942.98 | $961.58 | $1,292.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.25 / $1,153.24 / $1,830.81
| Professional | | $980.25 | $1,153.24 | $1,830.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,264.01 / $1,937.08
| Professional | | $150.00 | $1,264.01 | $1,937.08 |
- 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
- $935.50 / $1,339.66 / $2,061.44
| Professional | | $935.50 | $1,339.66 | $2,061.44 |