- 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
- $825.33 / $913.34 / $1,109.77
| Professional | | $825.33 | $913.34 | $1,109.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.38 / $1,012.21 / $1,599.60
| Professional | | $860.38 | $1,012.21 | $1,599.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,151.41 / $1,768.67
| Professional | | $150.00 | $1,151.41 | $1,768.67 |
- 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
- $746.57 / $1,171.36 / $1,803.10
| Professional | | $746.57 | $1,171.36 | $1,803.10 |