- 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
- $770.30 / $821.47 / $1,007.86
| Professional | | $770.30 | $821.47 | $1,007.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.68 / $972.56 / $1,492.27
| Professional | | $826.68 | $972.56 | $1,492.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,065.05 / $1,587.96
| Professional | | $150.00 | $1,065.05 | $1,587.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $5,979.00 / $9,764.00
| Facility | | $3,219.00 | $5,979.00 | $9,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.01 / $1,100.71 / $1,700.23
| Professional | | $681.01 | $1,100.71 | $1,700.23 |