- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $14,791.08 / $29,512.09
| Facility | | $3,801.89 | $14,791.08 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $5,128.61
| Professional | | $3,311.31 | $4,073.80 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,168.69 / $22,387.21
| Facility | | $2,754.23 | $4,168.69 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $7,943.28 / $26,302.68
| Professional | | $6,606.93 | $7,943.28 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $4,677.35
| Professional | | $3,311.31 | $3,311.31 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,466.84 / $4,897.79
| Professional | | $3,311.31 | $4,466.84 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,897.79 / $5,495.41
| Facility | | $2,290.87 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $8,128.31
| Professional | | $1,905.46 | $2,290.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,311.31 / $3,311.31
| Professional | | $1,479.11 | $3,311.31 | $3,311.31 |