- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,025.60 / $10,964.78
| Facility | | $3,890.45 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $616.60 / $1,202.26
| Professional | | $478.63 | $616.60 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,047.13 / $1,230.27
| Professional | | $467.74 | $1,047.13 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $870.96 / $1,412.54
| Professional | | $616.60 | $870.96 | $1,412.54 |
- 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
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $1,412.54
| Professional | | $501.19 | $676.08 | $1,412.54 |