- 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
- $1,698.24 / $2,511.89 / $4,365.16
| Professional | | $1,698.24 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $16,595.87 / $22,908.68
| Facility | | $14,125.38 | $16,595.87 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $3,235.94
| Professional | | $1,659.59 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $5,248.07
| Professional | | $1,778.28 | $2,238.72 | $5,248.07 |
- 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
- $1,698.24 / $2,187.76 / $3,715.35
| Professional | | $1,698.24 | $2,187.76 | $3,715.35 |