- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $9,120.11 / $16,595.87
| Facility | | $2,511.89 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $2,511.89
| Professional | | $1,096.48 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,041.74
| Professional | | $1,258.93 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,630.27 / $4,570.88
| Professional | | $1,513.56 | $2,630.27 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,454.71 / $5,248.07
| Facility | | $1,096.48 | $2,454.71 | $5,248.07 |
- 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
- $1,412.54 / $2,238.72 / $3,548.13
| Professional | | $1,412.54 | $2,238.72 | $3,548.13 |