- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $5,128.61 / $7,762.47
| Facility | | $1,047.13 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $3,019.95
| Professional | | $933.25 | $1,071.52 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,918.31 / $15,135.61
| Professional | | $1,202.26 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,818.38
| Professional | | $1,023.29 | $1,621.81 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,089.30 / $2,290.87
| Professional | | $1,023.29 | $2,089.30 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,479.11 / $2,754.23
| Professional | | $891.25 | $1,479.11 | $2,754.23 |