- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,094.78 / $4,212.99 / $15,356.50
| Facility | | $3,094.78 | $4,212.99 | $15,356.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $3,474.32 / $3,795.48
| Professional | | $1,751.76 | $3,474.32 | $3,795.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.87 / $986.55 / $1,095.07
| Professional | | $896.87 | $986.55 | $1,095.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Facility | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $20,621.25 / $22,167.38
| Facility | | $1,897.74 | $20,621.25 | $22,167.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,572.00 / $3,795.48
| Professional | | $1,226.23 | $1,572.00 | $3,795.48 |