- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,918.31 / $8,128.31
| Facility | | $1,202.26 | $6,918.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,202.26 / $3,090.30
| Professional | | $707.95 | $1,202.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,122.02 / $6,165.95
| Professional | | $489.78 | $1,122.02 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $2,454.71
| Professional | | $912.01 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $2,137.96
| Professional | | $1,949.84 | $2,137.96 | $2,137.96 |
- 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
- $912.01 / $1,380.38 / $2,754.23
| Professional | | $912.01 | $1,380.38 | $2,754.23 |