- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $2,041.74
| Professional | | $870.96 | $1,047.13 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $1,905.46
| Professional | | $1,000.00 | $1,348.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $5,370.32 / $5,370.32
| Facility | | $954.99 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,513.56 / $2,344.23
| Professional | | $537.03 | $1,513.56 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $6,025.60 / $12,589.25
| Facility | | $1,230.27 | $6,025.60 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,202.26 / $2,187.76
| Professional | | $851.14 | $1,202.26 | $2,187.76 |