- 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
- $1,608.68 / $1,718.60 / $2,249.77
| Professional | | $1,608.68 | $1,718.60 | $2,249.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.88 / $2,144.56 / $3,209.39
| Professional | | $1,822.88 | $2,144.56 | $3,209.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $2,421.39 / $3,526.29
| Professional | | $350.00 | $2,421.39 | $3,526.29 |
- 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
- $1,557.87 / $2,444.30 / $3,545.76
| Professional | | $1,557.87 | $2,444.30 | $3,545.76 |