- 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
- $2,511.89 / $3,235.94 / $5,495.41
| Professional | | $2,511.89 | $3,235.94 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29,512.09 / $35,481.34 / $47,863.01
| Facility | | $29,512.09 | $35,481.34 | $47,863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $5,495.41
| Professional | | $3,235.94 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,548.13 / $4,677.35
| Professional | | $2,041.74 | $3,548.13 | $4,677.35 |
- 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
- $1,905.46 / $2,754.23 / $4,265.80
| Professional | | $1,905.46 | $2,754.23 | $4,265.80 |