- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $11,748.98 / $17,378.01
| Facility | | $2,570.40 | $11,748.98 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $3,467.37
| Professional | | $2,570.40 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,890.45 / $5,128.61
| Professional | | $3,715.35 | $3,890.45 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,120.11 / $20,892.96
| Facility | | $2,398.83 | $9,120.11 | $20,892.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $6,309.57
| Facility | | $2,754.23 | $3,311.31 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,715.35 / $4,365.16
| Facility | | $3,311.31 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,715.35
| Professional | | $1,548.82 | $2,187.76 | $3,715.35 |