- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,388.44 / $7,762.47
| Facility | | $1,698.24 | $3,388.44 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,311.31 / $8,317.64
| Professional | | $2,951.21 | $3,311.31 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $15,488.17 / $31,622.78
| Professional | | $3,467.37 | $15,488.17 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,128.61 / $8,912.51
| Professional | | $3,235.94 | $5,128.61 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,760.83 / $7,413.10
| Professional | | $3,019.95 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $87,096.36
| Facility | | $9,120.11 | $25,703.96 | $87,096.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,365.16 / $8,912.51
| Professional | | $2,454.71 | $4,365.16 | $8,912.51 |