- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,413.10 / $10,715.19
| Facility | | $5,495.41 | $7,413.10 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $933.25 / $1,819.70
| Professional | | $707.95 | $933.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $4,365.16
| Facility | | $2,290.87 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $3,090.30
| Professional | | $1,621.81 | $1,621.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,412.54
| Professional | | $912.01 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,265.80 / $6,606.93
| Facility | | $2,570.40 | $4,265.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,398.83
| Professional | | $1,096.48 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,365.16 / $5,248.07
| Facility | | $2,398.83 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,862.09
| Professional | | $645.65 | $977.24 | $1,862.09 |