- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,398.83
| Facility | | $1,258.93 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,288.25
| Professional | | $630.96 | $758.58 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,754.40 / $7,762.47
| Facility | | $4,786.30 | $5,754.40 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,348.96
| Professional | | $851.14 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,230.27
| Professional | | $501.19 | $758.58 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $602.56 / $1,000.00
| Professional | | $489.78 | $602.56 | $1,000.00 |