- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.77 / $3,236.42 / $5,898.29
| Facility | | $1,515.77 | $3,236.42 | $5,898.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.54 / $1,000.00 / $1,720.78
| Professional | | $817.54 | $1,000.00 | $1,720.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,462.79 / $4,127.52 / $6,413.71
| Facility | | $3,462.79 | $4,127.52 | $6,413.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.61 / $1,239.10 / $1,858.66
| Facility | | $702.61 | $1,239.10 | $1,858.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.39 / $1,055.39 / $1,055.39
| Professional | | $1,055.39 | $1,055.39 | $1,055.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.36 / $1,109.58 / $1,689.36
| Professional | | $814.36 | $1,109.58 | $1,689.36 |