- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $2,951.21
| Facility | | $1,230.27 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $2,630.27
| Professional | | $1,513.56 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $9,120.11
| Facility | | $6,760.83 | $6,760.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,344.23
| Professional | | $1,737.80 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,511.89 / $2,884.03
| Professional | | $1,258.93 | $2,511.89 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,495.41 / $14,454.40
| Facility | | $2,089.30 | $5,495.41 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $3,090.30
| Professional | | $1,513.56 | $1,905.46 | $3,090.30 |