- 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
- $786.80 / $872.53 / $1,039.36
| Professional | | $786.80 | $872.53 | $1,039.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.62 / $965.43 / $1,526.77
| Professional | | $820.62 | $965.43 | $1,526.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,078.03 / $1,613.84
| Professional | | $150.00 | $1,078.03 | $1,613.84 |
- 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
- $712.97 / $1,118.65 / $1,721.75
| Professional | | $712.97 | $1,118.65 | $1,721.75 |