- 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
- $2,290.87 / $2,691.53 / $4,677.35
| Professional | | $2,290.87 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,677.35
| Professional | | $2,344.23 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $5,623.41
| Professional | | $2,570.40 | $3,311.31 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,548.13 / $6,165.95
| Facility | | $2,570.40 | $3,548.13 | $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
- $2,137.96 / $2,951.21 / $5,370.32
| Professional | | $2,137.96 | $2,951.21 | $5,370.32 |