- 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 / $3,981.07
| Professional | | $2,511.89 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $3,548.13 / $4,466.84
| Professional | | $977.24 | $3,548.13 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $9,120.11 / $20,417.38
| Facility | | $2,344.23 | $9,120.11 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,737.80 / $4,897.79
| Professional | | $1,621.81 | $1,737.80 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,235.94 / $6,165.95
| Facility | | $2,511.89 | $3,235.94 | $6,165.95 |
- 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 |