- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,760.64 / $7,701.06 / $20,846.20
| Facility | | $4,760.64 | $7,701.06 | $20,846.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,474.36 / $4,336.42 / $4,440.91
| Professional | | $3,474.36 | $4,336.42 | $4,440.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.34 / $10,296.85 / $16,311.66
| Facility | | $2,711.34 | $10,296.85 | $16,311.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,428.12 / $4,986.35 / $24,152.68
| Professional | | $3,428.12 | $4,986.35 | $24,152.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,455.42 / $8,489.98 / $15,281.96
| Facility | | $3,455.42 | $8,489.98 | $15,281.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,500.48 / $5,224.60 / $9,617.73
| Facility | | $3,500.48 | $5,224.60 | $9,617.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $2,194.33 / $26,018.51
| Professional | | $2,194.33 | $2,194.33 | $26,018.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $2,194.33 / $3,134.76
| Professional | | $2,194.33 | $2,194.33 | $3,134.76 |