- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.82 / $1,181.15 / $1,401.12
| Professional | | $1,088.82 | $1,181.15 | $1,401.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.10 / $1,304.83 / $2,111.21
| Professional | | $1,109.10 | $1,304.83 | $2,111.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,430.64 / $2,183.96
| Professional | | $150.00 | $1,430.64 | $2,183.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.47 / $1,513.25 / $2,328.84
| Professional | | $964.47 | $1,513.25 | $2,328.84 |