- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,128.31 / $16,218.10
| Facility | | $3,162.28 | $8,128.31 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $2,041.74
| Professional | | $1,023.29 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,549.93 / $10,964.78
| Facility | | $7,585.78 | $9,549.93 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,778.28 / $7,943.28
| Facility | | $851.14 | $1,778.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $9,549.93
| Professional | | $1,862.09 | $2,511.89 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $5,623.41
| Facility | | $912.01 | $1,778.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,162.28
| Professional | | $1,862.09 | $2,454.71 | $3,162.28 |