- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,495.41 / $6,165.95
| Facility | | $3,981.07 | $5,495.41 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $3,388.44
| Professional | | $1,122.02 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $1,995.26
| Professional | | $870.96 | $1,174.90 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,318.26 / $2,398.83
| Professional | | $181.97 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $18,620.87
| Facility | | $3,715.35 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,548.82 / $2,290.87
| Professional | | $1,023.29 | $1,548.82 | $2,290.87 |