- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,778.28
| Professional | | $794.33 | $1,023.29 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $19,952.62 / $27,542.29
| Facility | | $16,982.44 | $19,952.62 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,380.38
| Professional | | $812.83 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $1,445.44
| Professional | | $812.83 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $891.25 / $1,380.38
| Professional | | $630.96 | $891.25 | $1,380.38 |