- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $4,897.79
| Facility | | $1,258.93 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $2,137.96
| Professional | | $1,071.52 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,054.61 / $26,302.68
| Facility | | $9,549.93 | $19,054.61 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,344.23
| Professional | | $1,047.13 | $1,479.11 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,148.15 / $1,288.25
| Facility | | $1,096.48 | $1,148.15 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,454.71
| Professional | | $1,096.48 | $1,479.11 | $2,454.71 |
- 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
- $1,023.29 / $1,318.26 / $2,137.96
| Professional | | $1,023.29 | $1,318.26 | $2,137.96 |