- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $2,398.83
| Facility | | $1,258.93 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,511.89
| Professional | | $1,122.02 | $1,380.38 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $15,848.93 / $21,379.62
| Facility | | $13,182.57 | $15,848.93 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $2,041.74
| Professional | | $1,122.02 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,884.03
| Professional | | $1,071.52 | $1,513.56 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,495.41 / $9,772.37
| Facility | | $2,454.71 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $2,187.76
| Professional | | $977.24 | $1,258.93 | $2,187.76 |