- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,285.12 / $4,106.39 / $23,707.60
| Facility | | $3,285.12 | $4,106.39 | $23,707.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.98 / $3,723.14 / $4,927.68
| Professional | | $2,983.98 | $3,723.14 | $4,927.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,702.53 / $3,783.54 / $20,586.59
| Facility | | $2,702.53 | $3,783.54 | $20,586.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,668.70 / $6,668.70 / $7,989.86
| Professional | | $6,668.70 | $6,668.70 | $7,989.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.12 / $3,285.12 / $4,653.92
| Professional | | $3,285.12 | $3,285.12 | $4,653.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,475.20 / $8,212.79
| Facility | | $5,475.20 | $5,475.20 | $8,212.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.32 / $2,299.58 / $8,578.87
| Professional | | $1,916.32 | $2,299.58 | $8,578.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,285.12 / $3,285.12 / $3,285.12
| Professional | | $3,285.12 | $3,285.12 | $3,285.12 |