- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,888.44 / $10,715.19
| Facility | | $3,090.30 | $5,888.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $851.14 / $2,187.76
| Professional | | $575.44 | $851.14 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,023.29 / $2,454.71
| Professional | | $616.60 | $1,023.29 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $1,737.80
| Professional | | $1,202.26 | $1,318.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,786.30 / $7,585.78
| Facility | | $3,162.28 | $4,786.30 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,047.13 / $3,162.28
| Professional | | $616.60 | $1,047.13 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,128.61 / $8,511.38
| Facility | | $2,570.40 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $851.14 / $1,905.46
| Professional | | $457.09 | $851.14 | $1,905.46 |