- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,165.95 / $12,589.25
| Facility | | $2,951.21 | $6,165.95 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $2,041.74 / $5,128.61
| Facility | | $691.83 | $2,041.74 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,202.26 / $2,290.87
| Facility | | $371.54 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $1,000.00
| Professional | | $851.14 | $851.14 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,513.56
| Facility | | $691.83 | $912.01 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $10,232.93 / $16,982.44
| Facility | | $933.25 | $10,232.93 | $16,982.44 |