- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,011.87 / $7,762.47
| Facility | | $2,137.96 | $5,011.87 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $5,754.40 / $7,244.36
| Professional | | $616.60 | $5,754.40 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $12,589.25 / $17,378.01
| Professional | | $776.25 | $12,589.25 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $16,218.10
| Professional | | $1,318.26 | $1,318.26 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $57,543.99
| Facility | | $9,120.11 | $25,703.96 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $616.60 / $20,417.38
| Professional | | $331.13 | $616.60 | $20,417.38 |