- 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
- $2,187.76 / $2,818.38 / $6,760.83
| Professional | | $2,187.76 | $2,818.38 | $6,760.83 |
- 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
- $2,137.96 / $3,019.95 / $3,548.13
| Professional | | $2,137.96 | $3,019.95 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,019.95 / $3,890.45
| Professional | | $1,778.28 | $3,019.95 | $3,890.45 |
- 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
- $1,737.80 / $2,454.71 / $3,715.35
| Professional | | $1,737.80 | $2,454.71 | $3,715.35 |