- 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
- $2,187.76 / $2,818.38 / $5,011.87
| Professional | | $2,187.76 | $2,818.38 | $5,011.87 |
- 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
- $2,187.76 / $3,311.31 / $3,890.45
| Professional | | $2,187.76 | $3,311.31 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,162.28 / $5,495.41
| Professional | | $2,089.30 | $3,162.28 | $5,495.41 |
- 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
- $1,905.46 / $2,511.89 / $4,265.80
| Professional | | $1,905.46 | $2,511.89 | $4,265.80 |