- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $11,748.98 / $22,908.68
| Facility | | $3,311.31 | $11,748.98 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,801.89 / $5,248.07
| Professional | | $3,311.31 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,128.61 / $6,760.83
| Professional | | $4,786.30 | $5,128.61 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $11,748.98 / $27,542.29
| Facility | | $3,090.30 | $11,748.98 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,265.80 / $8,709.64
| Facility | | $3,548.13 | $4,265.80 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,786.30 / $5,754.40
| Facility | | $4,265.80 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $4,786.30
| Professional | | $1,995.26 | $2,884.03 | $4,786.30 |