- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $8,912.51 / $16,982.44
| Facility | | $2,511.89 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $3,890.45
| Professional | | $2,511.89 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,801.89 / $5,011.87
| Professional | | $3,630.78 | $3,801.89 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $8,912.51 / $20,417.38
| Facility | | $2,344.23 | $8,912.51 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,951.21 / $4,570.88
| Facility | | $2,137.96 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $4,365.16
| Facility | | $3,235.94 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $3,630.78
| Professional | | $1,513.56 | $2,137.96 | $3,630.78 |