- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $9,120.11 / $16,595.87
| Facility | | $2,089.30 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,659.59 / $2,089.30
| Professional | | $977.24 | $1,659.59 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,318.26 / $1,698.24
| Professional | | $1,047.13 | $1,318.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,187.76 / $3,801.89
| Professional | | $1,258.93 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,089.30 / $4,365.16
| Facility | | $977.24 | $2,089.30 | $4,365.16 |
- 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
- $1,202.26 / $1,905.46 / $3,019.95
| Professional | | $1,202.26 | $1,905.46 | $3,019.95 |