- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,073.80 / $4,897.79
| Facility | | $2,290.87 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $4,073.80
| Professional | | $2,187.76 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $30,199.52 / $41,686.94
| Facility | | $12,589.25 | $30,199.52 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $3,162.28
| Professional | | $1,659.59 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $2,754.23
| Facility | | $2,344.23 | $2,398.83 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $4,897.79
| Professional | | $2,089.30 | $3,019.95 | $4,897.79 |
- 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
- $1,995.26 / $2,630.27 / $4,265.80
| Professional | | $1,995.26 | $2,630.27 | $4,265.80 |