- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,760.83 / $17,782.79
| Facility | | $3,311.31 | $6,760.83 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $3,890.45
| Professional | | $2,344.23 | $3,090.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $16,595.87
| Facility | | $3,630.78 | $5,011.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $2,691.53 / $6,165.95
| Professional | | $338.84 | $2,691.53 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $6,309.57 / $16,595.87
| Facility | | $2,570.40 | $6,309.57 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,754.40 / $10,471.29
| Professional | | $4,570.88 | $5,754.40 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,630.78 / $4,677.35
| Facility | | $1,659.59 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $4,570.88
| Professional | | $1,659.59 | $2,344.23 | $4,570.88 |