- 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 / $5,248.07
| Professional | | $2,511.89 | $3,235.94 | $5,248.07 |
- 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
- $2,570.40 / $3,715.35 / $4,365.16
| Professional | | $2,570.40 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,162.28 / $4,570.88
| Professional | | $1,949.84 | $3,162.28 | $4,570.88 |
- 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
- $1,659.59 / $2,511.89 / $4,073.80
| Professional | | $1,659.59 | $2,511.89 | $4,073.80 |