- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $2,754.23
| Professional | | $1,380.38 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,547.09 / $29,512.09 / $39,810.72
| Facility | | $24,547.09 | $29,512.09 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $1,513.56
| Professional | | $891.25 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,456.54 / $12,022.64
| Facility | | $2,511.89 | $6,456.54 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $2,187.76
| Professional | | $977.24 | $1,288.25 | $2,187.76 |