- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.02 / $1,125.30 / $1,346.30
| Professional | | $1,021.02 | $1,125.30 | $1,346.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.57 / $1,245.38 / $1,982.07
| Professional | | $1,058.57 | $1,245.38 | $1,982.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,371.72 / $2,192.08
| Professional | | $150.00 | $1,371.72 | $2,192.08 |
- 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
- $923.03 / $1,448.24 / $2,228.67
| Professional | | $923.03 | $1,448.24 | $2,228.67 |