- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,235.94
| Facility | | $2,089.30 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,818.38
| Professional | | $1,023.29 | $1,023.29 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $10,232.93 / $26,302.68
| Facility | | $4,786.30 | $10,232.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,311.31 / $3,311.31
| Professional | | $3,090.30 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,606.93 / $9,332.54
| Facility | | $2,884.03 | $6,606.93 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,265.80 / $10,000.00
| Facility | | $1,445.44 | $4,265.80 | $10,000.00 |