- 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
- $630.96 / $758.58 / $1,737.80
| Professional | | $630.96 | $758.58 | $1,737.80 |
- 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
- $588.84 / $1,288.25 / $1,621.81
| Professional | | $588.84 | $1,288.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $1,737.80
| Professional | | $776.25 | $1,122.02 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,258.93
| Professional | | $1,230.27 | $1,230.27 | $1,258.93 |
- 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
- $602.56 / $933.25 / $1,905.46
| Professional | | $602.56 | $933.25 | $1,905.46 |