- 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
- $2,290.87 / $2,951.21 / $6,025.60
| Professional | | $2,290.87 | $2,951.21 | $6,025.60 |
- 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 / $3,801.89 / $4,466.84
| Professional | | $2,630.27 | $3,801.89 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,466.84 / $11,748.98
| Facility | | $3,801.89 | $4,466.84 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,467.37 / $5,623.41
| Professional | | $2,187.76 | $3,467.37 | $5,623.41 |
- 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
- $1,995.26 / $2,630.27 / $4,786.30
| Professional | | $1,995.26 | $2,630.27 | $4,786.30 |