- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $10,715.19
| Facility | | $3,162.28 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,137.96 / $7,943.28
| Professional | | $1,348.96 | $2,137.96 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $25,703.96 / $56,234.13
| Facility | | $15,848.93 | $25,703.96 | $56,234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $4,168.69
| Professional | | $2,238.72 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Professional | | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $8,709.64 / $8,709.64
| Professional | | $575.44 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,760.83 / $12,882.50
| Facility | | $2,630.27 | $6,760.83 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $5,128.61
| Professional | | $1,174.90 | $1,862.09 | $5,128.61 |