- 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
- $1,038.20 / $1,052.57 / $1,305.35
| Professional | | $1,038.20 | $1,052.57 | $1,305.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.08 / $1,149.51 / $1,934.04
| Professional | | $977.08 | $1,149.51 | $1,934.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,300.83 / $2,009.72
| Professional | | $150.00 | $1,300.83 | $2,009.72 |
- 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
- $847.57 / $1,329.84 / $2,046.97
| Professional | | $847.57 | $1,329.84 | $2,046.97 |