- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,454.71 / $7,762.47
| Facility | | $1,023.29 | $2,454.71 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,023.29 / $2,951.21
| Professional | | $977.24 | $1,023.29 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,071.52 / $1,288.25
| Professional | | $977.24 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,380.38 / $2,570.40
| Professional | | $912.01 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,041.74 / $2,290.87
| Professional | | $912.01 | $2,041.74 | $2,290.87 |
- 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
- $870.96 / $1,348.96 / $2,691.53
| Professional | | $870.96 | $1,348.96 | $2,691.53 |