- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,346.46 / $7,585.86 / $18,248.80
| Facility | | $5,346.46 | $7,585.86 | $18,248.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.08 / $3,191.38 / $8,645.31
| Professional | | $1,061.08 | $3,191.38 | $8,645.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,348.53 / $6,935.29 / $14,369.14
| Facility | | $4,348.53 | $6,935.29 | $14,369.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.59 / $3,128.50 / $7,308.73
| Professional | | $1,015.59 | $3,128.50 | $7,308.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $731.90 / $2,058.67 / $4,712.60
| Facility | | $731.90 | $2,058.67 | $4,712.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.00 / $10,880.52 / $10,880.52
| Professional | | $913.00 | $10,880.52 | $10,880.52 |