- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,269.95 / $7,185.14 / $20,437.20
| Facility | | $3,269.95 | $7,185.14 | $20,437.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,043.72 / $2,364.88
| Professional | | $2,043.72 | $2,043.72 | $2,364.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,802.74 / $5,337.03 / $11,386.44
| Facility | | $4,802.74 | $5,337.03 | $11,386.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.83 / $1,897.74 / $1,897.74
| Professional | | $1,167.83 | $1,897.74 | $1,897.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,271.92 / $10,672.75 / $12,807.85
| Facility | | $5,271.92 | $10,672.75 | $12,807.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,962.48 / $9,011.35
| Professional | | $2,919.60 | $3,962.48 | $9,011.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.07 / $2,398.08 / $3,052.10
| Professional | | $2,180.07 | $2,398.08 | $3,052.10 |