- 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
- $1,148.15 / $1,445.44 / $2,511.89
| Professional | | $1,148.15 | $1,445.44 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $19,498.45 / $26,302.68
| Facility | | $16,218.10 | $19,498.45 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $1,905.46
| Professional | | $1,148.15 | $1,621.81 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $2,041.74
| Professional | | $1,000.00 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,905.46
| Professional | | $912.01 | $1,258.93 | $1,905.46 |