- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $17,782.79 / $17,782.79
| Facility | | $2,398.83 | $17,782.79 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,862.09 / $10,232.93
| Professional | | $741.31 | $1,862.09 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,318.26 / $8,317.64
| Professional | | $602.56 | $1,318.26 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,513.56 / $15,135.61
| Professional | | $588.84 | $1,513.56 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $23,988.33
| Facility | | $4,466.84 | $8,128.31 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $5,128.61 / $11,481.54
| Professional | | $870.96 | $5,128.61 | $11,481.54 |