- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $7,762.47
| Facility | | $1,202.26 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $3,090.30
| Professional | | $776.25 | $1,202.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $1,412.54
| Professional | | $1,148.15 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $2,511.89
| Professional | | $912.01 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $2,137.96
| Professional | | $1,995.26 | $2,137.96 | $2,137.96 |
- 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
- $912.01 / $1,380.38 / $2,754.23
| Professional | | $912.01 | $1,380.38 | $2,754.23 |