- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.33 / $1,059.20 / $1,059.20
| Professional | | $919.33 | $1,059.20 | $1,059.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.03 / $1,260.04 / $1,260.04
| Professional | | $882.03 | $1,260.04 | $1,260.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,065.00 / $13,831.00 / $44,924.00
| Facility | | $6,065.00 | $13,831.00 | $44,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.14 / $1,275.22 / $1,792.60
| Professional | | $1,094.14 | $1,275.22 | $1,792.60 |