- 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
- $1,159.41 / $1,184.36 / $1,584.89
| Professional | | $1,159.41 | $1,184.36 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.69 / $1,417.28 / $2,255.07
| Professional | | $1,204.69 | $1,417.28 | $2,255.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,543.31 / $2,386.33
| Professional | | $300.00 | $1,543.31 | $2,386.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $4,086.00 / $7,409.00
| Facility | | $2,838.00 | $4,086.00 | $7,409.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.13 / $1,649.95 / $2,261.10
| Professional | | $1,022.13 | $1,649.95 | $2,261.10 |