- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $7,762.47
| Facility | | $1,698.24 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $3,715.35
| Professional | | $912.01 | $1,778.28 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $2,137.96
| Professional | | $1,445.44 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $3,630.78
| Professional | | $1,230.27 | $1,621.81 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,162.28 / $3,162.28
| Professional | | $2,884.03 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,754.40 / $26,302.68
| Facility | | $1,445.44 | $5,754.40 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,862.09 / $3,981.07
| Professional | | $1,122.02 | $1,862.09 | $3,981.07 |