- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,090.30 / $6,309.57
| Facility | | $1,445.44 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $4,786.30
| Professional | | $1,047.13 | $1,258.93 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $660.69 / $1,000.00
| Facility | | $204.17 | $660.69 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $295.12 / $891.25
| Professional | | $281.84 | $295.12 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,412.54 / $2,238.72
| Facility | | $707.95 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,548.82 / $2,344.23
| Facility | | $794.33 | $1,548.82 | $2,344.23 |