- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $7,762.47
| Facility | | $1,513.56 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,513.56 / $3,388.44
| Professional | | $794.33 | $1,513.56 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,778.28
| Professional | | $1,479.11 | $1,479.11 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $3,090.30
| Professional | | $1,047.13 | $1,584.89 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,691.53
| Professional | | $2,454.71 | $2,454.71 | $2,691.53 |
- 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
- $1,047.13 / $1,584.89 / $3,388.44
| Professional | | $1,047.13 | $1,584.89 | $3,388.44 |