- 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
- $806.19 / $891.47 / $1,063.08
| Professional | | $806.19 | $891.47 | $1,063.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.74 / $989.10 / $1,562.32
| Professional | | $840.74 | $989.10 | $1,562.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,095.81 / $1,654.13
| Professional | | $150.00 | $1,095.81 | $1,654.13 |
- 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
- $729.20 / $1,144.10 / $1,761.14
| Professional | | $729.20 | $1,144.10 | $1,761.14 |