- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,073.80 / $6,456.54
| Facility | | $1,096.48 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,096.48 / $2,818.38
| Professional | | $977.24 | $1,096.48 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,398.83 / $7,943.28
| Professional | | $1,047.13 | $2,398.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $2,951.21
| Professional | | $1,047.13 | $1,548.82 | $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
- $2,344.23 / $12,022.64 / $26,302.68
| Facility | | $2,344.23 | $12,022.64 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,951.21
| Professional | | $933.25 | $1,380.38 | $2,951.21 |