- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $8,709.64 / $16,595.87
| Facility | | $2,454.71 | $8,709.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $3,890.45
| Professional | | $2,454.71 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $4,897.79
| Professional | | $3,467.37 | $3,715.35 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $8,912.51 / $19,952.62
| Facility | | $2,290.87 | $8,912.51 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $6,025.60
| Facility | | $2,630.27 | $3,162.28 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $4,168.69
| Facility | | $3,162.28 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,467.37
| Professional | | $1,479.11 | $2,089.30 | $3,467.37 |