- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $10,715.19 / $20,892.96
| Facility | | $2,691.53 | $10,715.19 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $4,265.80
| Professional | | $2,511.89 | $3,090.30 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $15,848.93
| Facility | | $2,187.76 | $3,235.94 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,677.35 / $18,620.87
| Professional | | $2,290.87 | $4,677.35 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,311.31
| Professional | | $2,344.23 | $2,344.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $3,467.37
| Professional | | $2,344.23 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,467.37 / $3,890.45
| Facility | | $1,621.81 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $5,754.40
| Professional | | $1,348.96 | $1,621.81 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,344.23 / $2,344.23
| Professional | | $1,047.13 | $2,344.23 | $2,344.23 |