- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,137.96 / $7,762.47
| Facility | | $1,148.15 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,148.15 / $2,884.03
| Professional | | $741.31 | $1,148.15 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,122.02 / $19,952.62
| Professional | | $489.78 | $1,122.02 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,398.83
| Professional | | $831.76 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,041.74
| Professional | | $1,905.46 | $1,905.46 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $12,882.50 / $26,915.35
| Facility | | $3,311.31 | $12,882.50 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,630.27
| Professional | | $870.96 | $1,288.25 | $2,630.27 |