- 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
- $616.36 / $648.79 / $4,152.79
| Professional | | $616.36 | $648.79 | $4,152.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,671.43 / $21,503.38 / $23,906.61
| Facility | | $16,671.43 | $21,503.38 | $23,906.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,074.00 / $7,819.00 / $19,195.00
| Facility | | $5,074.00 | $7,819.00 | $19,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.58 / $1,213.53 / $28,397.73
| Professional | | $424.58 | $1,213.53 | $28,397.73 |