- 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
- $1,778.28 / $2,290.87 / $3,890.45
| Professional | | $1,778.28 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $19,498.45 / $26,302.68
| Facility | | $16,218.10 | $19,498.45 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $3,890.45
| Professional | | $2,290.87 | $3,235.94 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $4,265.80
| Professional | | $1,412.54 | $2,454.71 | $4,265.80 |
- 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
- $1,412.54 / $1,949.84 / $2,951.21
| Professional | | $1,412.54 | $1,949.84 | $2,951.21 |