- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $5,495.41 / $11,481.54
| Facility | | $1,230.27 | $5,495.41 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,370.32 / $7,762.47
| Professional | | $3,235.94 | $5,370.32 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $21,379.62 / $33,113.11
| Facility | | $9,332.54 | $21,379.62 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $4,677.35
| Professional | | $3,467.37 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $5,248.07
| Professional | | $32.36 | $33.11 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $5,128.61 / $10,715.19
| Facility | | $676.08 | $5,128.61 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,888.44 / $10,715.19
| Professional | | $3,548.13 | $5,888.44 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |