- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,073.80 / $7,762.47
| Facility | | $1,071.52 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,071.52 / $1,445.44
| Professional | | $954.99 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,235.94 / $7,079.46
| Professional | | $1,148.15 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,951.21
| Professional | | $1,023.29 | $1,380.38 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,137.96 / $2,398.83
| Professional | | $1,023.29 | $2,137.96 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $8,128.31 / $26,302.68
| Facility | | $1,023.29 | $8,128.31 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,754.23
| Professional | | $933.25 | $1,348.96 | $2,754.23 |