- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $2,818.38
| Facility | | $1,230.27 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,238.72
| Professional | | $1,380.38 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $18,197.01
| Facility | | $13,182.57 | $13,182.57 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,137.96
| Professional | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $2,691.53
| Professional | | $1,148.15 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $19,498.45
| Facility | | $3,715.35 | $7,762.47 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $2,818.38
| Professional | | $1,412.54 | $1,862.09 | $2,818.38 |