- 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
- $953.07 / $1,050.95 / $1,232.08
| Professional | | $953.07 | $1,050.95 | $1,232.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.20 / $1,162.58 / $1,849.30
| Professional | | $988.20 | $1,162.58 | $1,849.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,301.13 / $1,956.43
| Professional | | $150.00 | $1,301.13 | $1,956.43 |
- 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
- $982.70 / $1,156.81 / $2,045.60
| Professional | | $982.70 | $1,156.81 | $2,045.60 |