- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $9,120.11 / $16,595.87
| Facility | | $2,691.53 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,187.76 / $2,691.53
| Professional | | $977.24 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $1,995.26
| Professional | | $1,148.15 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,818.38 / $5,011.87
| Professional | | $1,621.81 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,630.27 / $5,623.41
| Facility | | $977.24 | $2,630.27 | $5,623.41 |
- 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
- $1,548.82 / $2,290.87 / $3,801.89
| Professional | | $1,548.82 | $2,290.87 | $3,801.89 |