- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $4,897.79
| Facility | | $2,344.23 | $3,162.28 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $5,248.07
| Professional | | $2,089.30 | $2,454.71 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,982.44 / $40,738.03 / $57,543.99
| Facility | | $16,982.44 | $40,738.03 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,715.35
| Professional | | $1,862.09 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $2,344.23
| Facility | | $1,995.26 | $2,187.76 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $4,466.84
| Professional | | $1,819.70 | $2,754.23 | $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
- $1,737.80 / $2,511.89 / $4,365.16
| Professional | | $1,737.80 | $2,511.89 | $4,365.16 |