- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $12,302.69 / $23,442.29
| Facility | | $3,467.37 | $12,302.69 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $5,011.87
| Professional | | $3,467.37 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,370.32 / $7,079.46
| Professional | | $5,011.87 | $5,370.32 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $12,589.25 / $28,183.83
| Facility | | $3,235.94 | $12,589.25 | $28,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,466.84 / $9,120.11
| Facility | | $3,715.35 | $4,466.84 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,011.87 / $6,025.60
| Facility | | $4,466.84 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $5,011.87
| Professional | | $2,089.30 | $3,019.95 | $5,011.87 |