- 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
- $616.60 / $776.25 / $1,584.89
| Professional | | $616.60 | $776.25 | $1,584.89 |
- 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
- $630.96 / $1,348.96 / $1,737.80
| Professional | | $630.96 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $1,737.80
| Professional | | $831.76 | $1,174.90 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- 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
- $741.31 / $1,000.00 / $1,862.09
| Professional | | $741.31 | $1,000.00 | $1,862.09 |