- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $3,235.94
| Professional | | $1,096.48 | $1,412.54 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $2,041.74
| Professional | | $870.96 | $1,174.90 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,348.96 / $2,398.83
| Professional | | $181.97 | $1,348.96 | $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 |