- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Facility | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $3,019.95
| Professional | | $1,380.38 | $1,621.81 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $15,135.61 / $20,417.38
| Facility | | $12,882.50 | $15,135.61 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $3,162.28
| Professional | | $1,949.84 | $2,511.89 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,467.37
| Professional | | $1,288.25 | $1,905.46 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $12,022.64
| Facility | | $2,511.89 | $7,244.36 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $2,884.03
| Professional | | $1,174.90 | $1,621.81 | $2,884.03 |