- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $2,238.72
| Professional | | $1,000.00 | $1,230.27 | $2,238.72 |
- 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
- $851.14 / $1,318.26 / $1,621.81
| Professional | | $851.14 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,630.27
| Professional | | $891.25 | $1,318.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,248.07 / $8,709.64
| Facility | | $1,584.89 | $5,248.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,290.87
| Professional | | $891.25 | $1,230.27 | $2,290.87 |