- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,265.80 / $7,762.47
| Facility | | $2,454.71 | $4,265.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,570.40 / $5,128.61
| Professional | | $2,290.87 | $2,570.40 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $8,511.38
| Professional | | $2,238.72 | $3,715.35 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,467.37 / $5,248.07
| Facility | | $2,630.27 | $3,467.37 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,981.07 / $6,025.60
| Professional | | $2,570.40 | $3,981.07 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $19,498.45
| Facility | | $3,090.30 | $5,128.61 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,715.35 / $5,128.61
| Professional | | $2,691.53 | $3,715.35 | $5,128.61 |