- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,495.41 / $9,549.93
| Facility | | $3,162.28 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $616.60 / $1,380.38
| Professional | | $501.19 | $616.60 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $12,022.64
| Facility | | $3,715.35 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,023.29 / $1,348.96
| Professional | | $501.19 | $1,023.29 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $870.96 / $1,348.96
| Professional | | $616.60 | $870.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $977.24
| Professional | | $870.96 | $870.96 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $741.31 / $1,348.96
| Professional | | $501.19 | $741.31 | $1,348.96 |