- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,511.89
| Facility | | $1,479.11 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $1,819.70
| Professional | | $1,148.15 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $7,413.10
| Facility | | $5,370.32 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $2,089.30
| Professional | | $1,288.25 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,041.74 / $2,570.40
| Professional | | $1,096.48 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,981.07 / $11,748.98
| Facility | | $1,548.82 | $3,981.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,630.27
| Professional | | $1,122.02 | $1,479.11 | $2,630.27 |