- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $4,786.30
| Facility | | $3,981.07 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $2,691.53
| Professional | | $758.58 | $1,174.90 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,698.24
| Professional | | $776.25 | $1,047.13 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,318.26 / $2,089.30
| Professional | | $151.36 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,187.76
| Professional | | $812.83 | $1,288.25 | $2,187.76 |