- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $5,128.61 / $7,762.47
| Facility | | $1,174.90 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $2,818.38
| Professional | | $912.01 | $1,047.13 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,818.38 / $7,079.46
| Professional | | $1,071.52 | $2,818.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $3,019.95
| Professional | | $1,000.00 | $1,202.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,238.72 / $2,630.27
| Professional | | $1,096.48 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,791.08 / $26,915.35
| Facility | | $3,311.31 | $14,791.08 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $2,398.83
| Professional | | $851.14 | $1,122.02 | $2,398.83 |