- 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
- $1,905.46 / $2,290.87 / $4,265.80
| Professional | | $1,905.46 | $2,290.87 | $4,265.80 |
- 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
- $2,041.74 / $3,090.30 / $3,630.78
| Professional | | $2,041.74 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $4,897.79
| Professional | | $1,819.70 | $2,570.40 | $4,897.79 |
- 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
- $1,659.59 / $2,187.76 / $3,801.89
| Professional | | $1,659.59 | $2,187.76 | $3,801.89 |