- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,454.71 / $7,762.47
| Facility | | $1,047.13 | $2,454.71 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,047.13 / $2,570.40
| Professional | | $549.54 | $1,047.13 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $1,230.27
| Professional | | $691.83 | $912.01 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,096.48 / $2,137.96
| Professional | | $724.44 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,862.09
| Professional | | $1,737.80 | $1,737.80 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,344.23
| Professional | | $776.25 | $1,122.02 | $2,344.23 |