- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,011.87 / $9,772.37
| Facility | | $1,288.25 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $2,570.40
| Professional | | $851.14 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $6,918.31 / $15,135.61
| Professional | | $933.25 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,445.44 / $3,019.95
| Professional | | $954.99 | $1,445.44 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $2,818.38
| Professional | | $1,380.38 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,479.11 / $2,630.27
| Professional | | $812.83 | $1,479.11 | $2,630.27 |