- 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
- $2,344.23 / $3,019.95 / $5,128.61
| Professional | | $2,344.23 | $3,019.95 | $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
- $1,819.70 / $2,570.40 / $3,019.95
| Professional | | $1,819.70 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $4,168.69
| Professional | | $1,905.46 | $2,630.27 | $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
- $1,778.28 / $2,290.87 / $3,981.07
| Professional | | $1,778.28 | $2,290.87 | $3,981.07 |