- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,623.41 / $10,715.19
| Facility | | $2,041.74 | $5,623.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,918.31 / $20,417.38
| Professional | | $2,290.87 | $6,918.31 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $11,481.54 / $23,988.33
| Facility | | $6,025.60 | $11,481.54 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $812.83 / $1,148.15
| Professional | | $645.65 | $812.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,187.76
| Professional | | $2,137.96 | $2,137.96 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $20,417.38
| Facility | | $8,511.38 | $12,022.64 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |