- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,467.37 / $4,897.79
| Facility | | $2,137.96 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $4,073.80
| Professional | | $2,041.74 | $2,454.71 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,952.62 / $27,542.29
| Facility | | $9,549.93 | $19,952.62 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $3,388.44
| Professional | | $1,698.24 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $2,454.71
| Facility | | $2,089.30 | $2,187.76 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,466.84
| Professional | | $1,949.84 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $3,715.35
| Professional | | $1,778.28 | $2,344.23 | $3,715.35 |