- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $7,762.47
| Facility | | $1,584.89 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,584.89 / $3,981.07
| Professional | | $870.96 | $1,584.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,778.28 / $2,041.74
| Professional | | $1,698.24 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,737.80 / $3,311.31
| Professional | | $1,174.90 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $2,884.03
| Professional | | $2,630.27 | $2,884.03 | $2,884.03 |
- 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
- $1,202.26 / $1,737.80 / $3,715.35
| Professional | | $1,202.26 | $1,737.80 | $3,715.35 |