- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $4,897.79
| Facility | | $1,380.38 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $3,090.30
| Professional | | $1,258.93 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $25,703.96 / $35,481.34
| Facility | | $10,232.93 | $25,703.96 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $3,090.30
| Professional | | $1,230.27 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,288.25 / $1,380.38
| Facility | | $1,174.90 | $1,288.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $3,388.44
| Professional | | $1,288.25 | $1,862.09 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,570.40
| Professional | | $1,148.15 | $1,479.11 | $2,570.40 |