- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $7,943.28 / $16,595.87
| Facility | | $2,290.87 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $3,467.37
| Professional | | $1,778.28 | $2,187.76 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,905.46 / $3,388.44
| Professional | | $1,621.81 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,981.07
| Professional | | $1,819.70 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $4,466.84
| Facility | | $1,819.70 | $2,511.89 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,238.72 / $3,890.45
| Professional | | $1,621.81 | $2,238.72 | $3,890.45 |