- 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
- $1,819.70 / $2,398.83 / $3,981.07
| Professional | | $1,819.70 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $19,054.61 / $26,302.68
| Facility | | $16,218.10 | $19,054.61 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $3,311.31
| Professional | | $1,995.26 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,754.23 / $3,388.44
| Professional | | $1,479.11 | $2,754.23 | $3,388.44 |
- 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 / $2,089.30 / $3,090.30
| Professional | | $1,412.54 | $2,089.30 | $3,090.30 |