- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,398.83
| Facility | | $1,202.26 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $3,630.78
| Professional | | $1,621.81 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $21,379.62 / $28,840.32
| Facility | | $18,197.01 | $21,379.62 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $2,818.38
| Professional | | $1,621.81 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $4,168.69
| Professional | | $1,548.82 | $2,137.96 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $6,456.54 / $12,022.64
| Facility | | $1,584.89 | $6,456.54 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,162.28
| Professional | | $1,412.54 | $1,862.09 | $3,162.28 |