- 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
- $1,045.81 / $1,125.34 / $1,490.17
| Professional | | $1,045.81 | $1,125.34 | $1,490.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.66 / $1,245.48 / $1,951.49
| Professional | | $1,058.66 | $1,245.48 | $1,951.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,411.92 / $2,097.92
| Professional | | $150.00 | $1,411.92 | $2,097.92 |
- 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
- $1,033.21 / $1,447.34 / $2,334.44
| Professional | | $1,033.21 | $1,447.34 | $2,334.44 |