- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $13,182.57 / $25,703.96
| Facility | | $3,311.31 | $13,182.57 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $5,248.07
| Professional | | $3,090.30 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $19,498.45
| Facility | | $2,630.27 | $3,548.13 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,888.44 / $22,908.68
| Professional | | $3,801.89 | $5,888.44 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $4,073.80
| Professional | | $2,884.03 | $2,884.03 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $4,265.80
| Professional | | $2,884.03 | $3,890.45 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,265.80 / $4,786.30
| Facility | | $1,995.26 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $7,244.36
| Professional | | $1,659.59 | $1,995.26 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,884.03 / $2,884.03
| Professional | | $1,288.25 | $2,884.03 | $2,884.03 |