- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,943.28 / $16,595.87
| Facility | | $3,162.28 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $5,623.41
| Professional | | $2,238.72 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $4,897.79
| Professional | | $2,041.74 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $5,128.61
| Professional | | $2,290.87 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,311.31 / $6,165.95
| Facility | | $2,398.83 | $3,311.31 | $6,165.95 |
- 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
- $2,238.72 / $3,090.30 / $5,495.41
| Professional | | $2,238.72 | $3,090.30 | $5,495.41 |