- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $9,120.11 / $16,595.87
| Facility | | $2,454.71 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $2,454.71
| Professional | | $1,479.11 | $1,905.46 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,570.40 / $4,570.88
| Professional | | $1,621.81 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,454.71 / $5,248.07
| Facility | | $1,318.26 | $2,454.71 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,467.37 / $4,073.80
| Professional | | $2,754.23 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,760.83 / $9,120.11
| Facility | | $2,454.71 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $3,890.45
| Professional | | $1,288.25 | $1,862.09 | $3,890.45 |