- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $13,803.84 / $26,915.35
| Facility | | $3,467.37 | $13,803.84 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $5,495.41
| Professional | | $3,235.94 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,801.89 / $20,417.38
| Facility | | $2,570.40 | $3,801.89 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,244.36 / $23,988.33
| Professional | | $6,025.60 | $7,244.36 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $4,265.80
| Professional | | $3,019.95 | $3,019.95 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,466.84 / $5,011.87
| Facility | | $2,089.30 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $7,585.78
| Professional | | $1,737.80 | $2,089.30 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |