- 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
- $2,630.27 / $3,311.31 / $6,760.83
| Professional | | $2,630.27 | $3,311.31 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $21,379.62 / $28,840.32
| Facility | | $18,197.01 | $21,379.62 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,981.07 / $4,570.88
| Professional | | $2,630.27 | $3,981.07 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $11,748.98
| Facility | | $3,801.89 | $5,128.61 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $6,456.54
| Professional | | $2,511.89 | $3,801.89 | $6,456.54 |
- 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
- $2,290.87 / $3,019.95 / $5,370.32
| Professional | | $2,290.87 | $3,019.95 | $5,370.32 |