- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $7,943.28 / $16,595.87
| Facility | | $3,019.95 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $4,466.84
| Professional | | $2,137.96 | $2,570.40 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,981.07
| Professional | | $1,905.46 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,090.30 / $5,011.87
| Professional | | $2,137.96 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $5,248.07
| Facility | | $2,290.87 | $3,162.28 | $5,248.07 |
- 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
- $2,187.76 / $2,951.21 / $5,370.32
| Professional | | $2,187.76 | $2,951.21 | $5,370.32 |