- 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
- $1,145.64 / $1,177.59 / $1,630.50
| Professional | | $1,145.64 | $1,177.59 | $1,630.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.14 / $1,448.40 / $2,242.23
| Professional | | $1,231.14 | $1,448.40 | $2,242.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,682.85 / $2,552.90
| Professional | | $150.00 | $1,682.85 | $2,552.90 |
- 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
- $1,071.79 / $1,681.64 / $2,422.65
| Professional | | $1,071.79 | $1,681.64 | $2,422.65 |