- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,630.78 / $4,897.79
| Facility | | $2,238.72 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $4,265.80
| Professional | | $2,137.96 | $2,511.89 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $29,512.09 / $39,810.72
| Facility | | $12,589.25 | $29,512.09 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $4,466.84
| Professional | | $2,089.30 | $2,754.23 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $2,691.53
| Facility | | $2,137.96 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $5,011.87
| Professional | | $2,187.76 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,623.41 / $12,022.64
| Facility | | $1,412.54 | $5,623.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,365.16
| Professional | | $1,949.84 | $2,630.27 | $4,365.16 |