- 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
- $1,142.98 / $1,238.21 / $1,329.55
| Professional | | $1,142.98 | $1,238.21 | $1,329.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.50 / $1,400.59 / $2,356.98
| Professional | | $1,190.50 | $1,400.59 | $2,356.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,581.29 / $2,313.67
| Professional | | $300.00 | $1,581.29 | $2,313.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $3,447.00 / $5,685.00
| Facility | | $2,569.00 | $3,447.00 | $5,685.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.40 / $1,603.77 / $2,471.57
| Professional | | $1,022.40 | $1,603.77 | $2,471.57 |