- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $11,481.54 / $18,620.87
| Facility | | $2,511.89 | $11,481.54 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $3,890.45
| Professional | | $2,754.23 | $3,162.28 | $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
- $2,454.71 / $9,549.93 / $22,387.21
| Facility | | $2,454.71 | $9,549.93 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $4,897.79
| Facility | | $2,398.83 | $3,235.94 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $3,890.45
| Professional | | $1,659.59 | $2,238.72 | $3,890.45 |