- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,495.41 / $7,762.47
| Facility | | $1,513.56 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $3,548.13
| Professional | | $977.24 | $1,513.56 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $7,079.46
| Professional | | $1,047.13 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $3,311.31
| Professional | | $1,230.27 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $2,884.03
| Professional | | $1,202.26 | $1,258.93 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,803.84 / $26,302.68
| Facility | | $2,344.23 | $13,803.84 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $3,235.94
| Professional | | $1,096.48 | $1,548.82 | $3,235.94 |