- 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
- $1,778.28 / $2,089.30 / $4,466.84
| Professional | | $1,778.28 | $2,089.30 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $4,466.84
| Professional | | $1,659.59 | $2,344.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $4,073.80
| Professional | | $1,819.70 | $2,630.27 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $4,897.79
| Facility | | $1,949.84 | $2,818.38 | $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 / $2,454.71 / $4,365.16
| Professional | | $1,778.28 | $2,454.71 | $4,365.16 |