- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $4,365.16
| Facility | | $1,258.93 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,949.84
| Professional | | $1,000.00 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $16,595.87 / $22,387.21
| Facility | | $13,803.84 | $16,595.87 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,258.93
| Professional | | $741.31 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,445.44 / $1,778.28
| Professional | | $831.76 | $1,445.44 | $1,778.28 |
- 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
- $831.76 / $1,202.26 / $1,778.28
| Professional | | $831.76 | $1,202.26 | $1,778.28 |