- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,646.56 / $11,718.32 / $21,998.27
| Facility | | $8,646.56 | $11,718.32 | $21,998.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.44 / $505.54 / $2,711.88
| Professional | | $222.44 | $505.54 | $2,711.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.02 / $799.03 / $15,405.17
| Facility | | $470.02 | $799.03 | $15,405.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.06 / $2,639.38 / $5,960.08
| Professional | | $1,214.06 | $2,639.38 | $5,960.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.20 / $1,832.18 / $14,162.72
| Facility | | $940.20 | $1,832.18 | $14,162.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.56 / $1,438.82 / $2,654.20
| Professional | | $420.56 | $1,438.82 | $2,654.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.06 / $2,929.71 / $3,237.20
| Professional | | $1,214.06 | $2,929.71 | $3,237.20 |