- 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
- $2,290.87 / $2,951.21 / $5,128.61
| Professional | | $2,290.87 | $2,951.21 | $5,128.61 |
- 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
- $2,454.71 / $3,467.37 / $4,073.80
| Professional | | $2,454.71 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $4,168.69
| Professional | | $1,862.09 | $3,019.95 | $4,168.69 |
- 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
- $1,621.81 / $2,454.71 / $3,890.45
| Professional | | $1,621.81 | $2,454.71 | $3,890.45 |