- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $7,762.47
| Facility | | $1,096.48 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,096.48 / $2,818.38
| Professional | | $588.84 | $1,096.48 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $19,952.62
| Professional | | $489.78 | $707.95 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,238.72
| Professional | | $812.83 | $1,202.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,949.84
| Professional | | $1,778.28 | $1,778.28 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $2,511.89
| Professional | | $831.76 | $1,288.25 | $2,511.89 |