- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,943.28 / $16,595.87
| Facility | | $2,511.89 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $3,801.89
| Professional | | $1,949.84 | $2,398.83 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,905.46 / $2,884.03
| Professional | | $1,778.28 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $4,365.16
| Professional | | $1,905.46 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $4,897.79
| Facility | | $1,905.46 | $2,754.23 | $4,897.79 |
- 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
- $1,778.28 / $2,398.83 / $4,265.80
| Professional | | $1,778.28 | $2,398.83 | $4,265.80 |