- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,501.51 / $9,663.58 / $18,551.84
| Facility | | $2,501.51 | $9,663.58 | $18,551.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.10 / $2,501.51 / $4,297.55
| Professional | | $2,449.10 | $2,501.51 | $4,297.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,440.22 / $5,196.63 / $5,196.63
| Professional | | $3,440.22 | $5,196.63 | $5,196.63 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $7,794.94 / $26,749.15 / $26,749.15
| Facility | | $7,794.94 | $26,749.15 | $26,749.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,971.25 / $28,971.25 / $42,039.53
| Professional | | $28,971.25 | $28,971.25 | $42,039.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,920.40 / $2,880.60 / $3,857.28
| Professional | | $1,920.40 | $2,880.60 | $3,857.28 |