- 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
- $1,380.38 / $1,778.28 / $3,090.30
| Professional | | $1,380.38 | $1,778.28 | $3,090.30 |
- 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
- $2,238.72 / $3,162.28 / $3,715.35
| Professional | | $2,238.72 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $3,235.94
| Professional | | $1,288.25 | $1,949.84 | $3,235.94 |
- 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
- $1,122.02 / $1,548.82 / $2,344.23
| Professional | | $1,122.02 | $1,548.82 | $2,344.23 |