- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $3,019.95
| Professional | | $933.25 | $1,288.25 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $2,089.30
| Professional | | $1,000.00 | $1,148.15 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,238.72
| Professional | | $1,202.26 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $15,135.61
| Facility | | $3,235.94 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,398.83
| Professional | | $933.25 | $1,348.96 | $2,398.83 |