- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.58 / $1,173.58 / $25,356.75
| Facility | | $1,173.58 | $1,173.58 | $25,356.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.55 / $1,173.58 / $1,776.04
| Professional | | $1,027.55 | $1,173.58 | $1,776.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,268.63 / $22,395.57 / $25,253.84
| Facility | | $17,268.63 | $22,395.57 | $25,253.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.11 / $1,529.70 / $2,209.60
| Professional | | $1,283.11 | $1,529.70 | $2,209.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.73 / $1,648.90 / $2,499.10
| Professional | | $1,399.73 | $1,648.90 | $2,499.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.57 / $1,654.42 / $2,537.96
| Professional | | $1,284.57 | $1,654.42 | $2,537.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,356.75 / $25,356.75 / $25,356.75
| Facility | | $25,356.75 | $25,356.75 | $25,356.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.55 / $1,173.58 / $1,842.08
| Professional | | $1,027.55 | $1,173.58 | $1,842.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.99 / $1,710.33 / $2,525.06
| Professional | | $1,341.99 | $1,710.33 | $2,525.06 |