- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $4,813.58 / $18,965.64
| Facility | | $3,706.14 | $4,813.58 | $18,965.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.73 / $1,291.11 / $1,300.33
| Professional | | $907.73 | $1,291.11 | $1,300.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.59 / $1,394.82 / $2,225.10
| Professional | | $1,185.59 | $1,394.82 | $2,225.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.91 / $1,374.69 / $2,442.12
| Professional | | $926.91 | $1,374.69 | $2,442.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $8,699.00 / $12,680.00
| Facility | | $3,599.00 | $8,699.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.85 / $1,272.58 / $1,848.52
| Professional | | $869.85 | $1,272.58 | $1,848.52 |