- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $9,120.11 / $16,595.87
| Facility | | $2,290.87 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,862.09 / $2,290.87
| Professional | | $1,071.52 | $1,862.09 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $1,862.09
| Professional | | $1,148.15 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $4,168.69
| Professional | | $1,380.38 | $2,398.83 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,238.72 / $4,786.30
| Facility | | $1,071.52 | $2,238.72 | $4,786.30 |
- 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
- $1,445.44 / $2,137.96 / $3,630.78
| Professional | | $1,445.44 | $2,137.96 | $3,630.78 |