- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $7,943.28 / $16,595.87
| Facility | | $2,691.53 | $7,943.28 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $4,168.69
| Professional | | $2,041.74 | $2,398.83 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $4,168.69
| Professional | | $2,089.30 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $5,011.87
| Professional | | $2,290.87 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $5,495.41
| Facility | | $2,290.87 | $3,090.30 | $5,495.41 |
- 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
- $1,905.46 / $2,630.27 / $4,677.35
| Professional | | $1,905.46 | $2,630.27 | $4,677.35 |