- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,786.30 / $10,232.93
| Facility | | $2,238.72 | $4,786.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $2,137.96 / $4,466.84
| Professional | | $691.83 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,120.11 / $16,595.87
| Facility | | $3,467.37 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,548.82
| Professional | | $588.84 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |