- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,897.79 / $25,118.86
| Facility | | $1,819.70 | $4,897.79 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,737.80 / $3,981.07
| Professional | | $707.95 | $1,737.80 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,258.93 / $2,951.21
| Professional | | $676.08 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $17,782.79 / $22,908.68
| Facility | | $8,128.31 | $17,782.79 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,412.54 / $3,801.89
| Professional | | $660.69 | $1,412.54 | $3,801.89 |