- 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
- $630.96 / $794.33 / $1,905.46
| Professional | | $630.96 | $794.33 | $1,905.46 |
- 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
- $660.69 / $1,412.54 / $1,778.28
| Professional | | $660.69 | $1,412.54 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,819.70
| Professional | | $794.33 | $1,122.02 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,230.27
| Professional | | $1,096.48 | $1,096.48 | $1,230.27 |
- 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
- $645.65 / $851.14 / $1,819.70
| Professional | | $645.65 | $851.14 | $1,819.70 |