- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,309.57 / $13,182.57
| Facility | | $2,398.83 | $6,309.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $5,370.32 / $9,549.93
| Professional | | $758.58 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $6,309.57
| Professional | | $1,023.29 | $1,023.29 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,621.81 / $10,471.29
| Professional | | $724.44 | $1,621.81 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $6,025.60 / $25,118.86
| Facility | | $1,122.02 | $6,025.60 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $7,079.46 / $41,686.94
| Professional | | $1,318.26 | $7,079.46 | $41,686.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $7,079.46 / $17,378.01
| Facility | | $2,951.21 | $7,079.46 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,479.11 / $8,709.64
| Professional | | $794.33 | $1,479.11 | $8,709.64 |