- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $9,549.93 / $18,197.01
| Facility | | $2,691.53 | $9,549.93 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,090.30 / $4,265.80
| Professional | | $2,691.53 | $3,090.30 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,168.69 / $5,495.41
| Professional | | $3,890.45 | $4,168.69 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $9,772.37 / $21,877.62
| Facility | | $2,511.89 | $9,772.37 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $5,128.61
| Professional | | $1,737.80 | $1,819.70 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $6,606.93
| Facility | | $2,691.53 | $3,467.37 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $4,677.35
| Facility | | $3,467.37 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,890.45
| Professional | | $1,621.81 | $2,344.23 | $3,890.45 |