- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,128.61 / $7,762.47
| Facility | | $1,096.48 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,096.48 / $2,951.21
| Professional | | $977.24 | $1,096.48 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $4,677.35 / $15,488.17
| Professional | | $1,047.13 | $4,677.35 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $2,951.21
| Professional | | $1,047.13 | $1,584.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,187.76 / $2,454.71
| Professional | | $1,023.29 | $2,187.76 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $61,659.50
| Facility | | $4,073.80 | $16,218.10 | $61,659.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $2,951.21
| Professional | | $870.96 | $1,412.54 | $2,951.21 |