- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,651.18 / $6,545.20 / $23,704.74
| Facility | | $2,651.18 | $6,545.20 | $23,704.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.14 / $2,956.24 / $4,297.55
| Professional | | $2,465.14 | $2,956.24 | $4,297.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $3,855.99 / $4,536.46
| Professional | | $3,855.99 | $3,855.99 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.53 / $4,339.22 / $5,774.03
| Professional | | $2,603.53 | $4,339.22 | $5,774.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,619.22 / $4,619.22 / $4,619.22
| Professional | | $4,619.22 | $4,619.22 | $4,619.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,479.55 / $2,880.60 / $3,857.28
| Professional | | $2,479.55 | $2,880.60 | $3,857.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,096.92 / $3,096.92 / $5,774.03
| Professional | | $3,096.92 | $3,096.92 | $5,774.03 |