- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,398.83
| Facility | | $1,230.27 | $1,698.24 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $2,089.30
| Professional | | $1,258.93 | $1,412.54 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,511.38
| Facility | | $6,309.57 | $6,309.57 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,995.26
| Professional | | $1,513.56 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,137.96 / $2,818.38
| Professional | | $1,122.02 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,890.45 / $7,762.47
| Facility | | $1,548.82 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,630.27
| Professional | | $1,230.27 | $1,584.89 | $2,630.27 |