- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,630.27 / $6,606.93
| Facility | | $1,202.26 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $1,584.89
| Professional | | $851.14 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,445.44 / $1,737.80
| Professional | | $933.25 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $1,659.59
| Professional | | $1,023.29 | $1,445.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $7,413.10 / $22,387.21
| Facility | | $1,096.48 | $7,413.10 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $11,748.98
| Professional | | $831.76 | $1,122.02 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $14,454.40 / $24,547.09
| Facility | | $5,495.41 | $14,454.40 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,621.81
| Professional | | $812.83 | $1,071.52 | $1,621.81 |