- 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
- $1,659.59 / $2,137.96 / $3,630.78
| Professional | | $1,659.59 | $2,137.96 | $3,630.78 |
- 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
- $1,621.81 / $2,344.23 / $2,754.23
| Professional | | $1,621.81 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $2,951.21
| Professional | | $1,348.96 | $2,290.87 | $2,951.21 |
- 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
- $1,318.26 / $1,819.70 / $2,754.23
| Professional | | $1,318.26 | $1,819.70 | $2,754.23 |