- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $7,943.28 / $16,595.87
| Facility | | $1,778.28 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $3,090.30
| Professional | | $1,258.93 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,238.72
| Professional | | $1,122.02 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,951.21
| Professional | | $1,318.26 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $3,090.30
| Facility | | $1,348.96 | $1,949.84 | $3,090.30 |
- 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
- $1,258.93 / $1,737.80 / $3,162.28
| Professional | | $1,258.93 | $1,737.80 | $3,162.28 |