- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,897.79 / $8,511.38
| Facility | | $2,691.53 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $2,187.76
| Professional | | $870.96 | $1,071.52 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $13,803.84 / $16,595.87
| Facility | | $6,606.93 | $13,803.84 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,737.80 / $2,137.96
| Professional | | $812.83 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $2,454.71
| Professional | | $1,096.48 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,659.59
| Professional | | $1,513.56 | $1,513.56 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,709.64 / $11,748.98
| Facility | | $5,754.40 | $8,709.64 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,754.23
| Professional | | $870.96 | $1,230.27 | $2,754.23 |