- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,128.61 / $6,918.31
| Facility | | $1,412.54 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $2,137.96 / $3,801.89
| Professional | | $426.58 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $549.54 / $1,258.93
| Professional | | $436.52 | $549.54 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,905.46 / $4,677.35
| Professional | | $398.11 | $1,905.46 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,691.53 / $5,248.07
| Professional | | $2,344.23 | $2,691.53 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,258.93 / $5,128.61
| Professional | | $380.19 | $1,258.93 | $5,128.61 |