- 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
- $1,584.89 / $2,089.30 / $3,311.31
| Professional | | $1,584.89 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $16,595.87 / $22,387.21
| Facility | | $13,803.84 | $16,595.87 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,187.76
| Professional | | $1,318.26 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,570.40 / $3,311.31
| Professional | | $1,230.27 | $2,570.40 | $3,311.31 |
- 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
- $1,230.27 / $1,862.09 / $2,630.27
| Professional | | $1,230.27 | $1,862.09 | $2,630.27 |