- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.93 / $1,318.17 / $1,925.57
| Professional | | $779.93 | $1,318.17 | $1,925.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,280.68 / $12,982.03 / $15,796.22
| Facility | | $4,280.68 | $12,982.03 | $15,796.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.20 / $646.65 / $646.65
| Professional | | $467.20 | $646.65 | $646.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,838.00 / $5,111.00 / $9,622.00
| Facility | | $2,838.00 | $5,111.00 | $9,622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.21 / $957.36 / $1,688.74
| Professional | | $550.21 | $957.36 | $1,688.74 |