- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $8,128.31 / $17,378.01
| Facility | | $3,548.13 | $8,128.31 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,890.45 / $8,709.64
| Professional | | $2,238.72 | $3,890.45 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,888.44 / $14,791.08
| Facility | | $3,890.45 | $5,888.44 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,890.45 / $7,244.36
| Professional | | $1,202.26 | $3,890.45 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $5,495.41
| Facility | | $3,162.28 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $954.99 / $954.99
| Professional | | $79.43 | $954.99 | $954.99 |