- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,356.56 / $7,600.19 / $18,283.29
| Facility | | $5,356.56 | $7,600.19 | $18,283.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.48 / $3,145.82 / $8,736.37
| Professional | | $1,022.48 | $3,145.82 | $8,736.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,356.75 / $6,948.40 / $14,396.29
| Facility | | $4,356.75 | $6,948.40 | $14,396.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.30 / $3,114.67 / $7,322.54
| Professional | | $968.30 | $3,114.67 | $7,322.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $692.83 / $1,979.50 / $4,693.26
| Facility | | $692.83 | $1,979.50 | $4,693.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.00 / $9,915.25 / $9,915.25
| Professional | | $857.00 | $9,915.25 | $9,915.25 |