- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,467.37 / $4,897.79
| Facility | | $1,995.26 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $3,715.35
| Professional | | $1,905.46 | $2,290.87 | $3,715.35 |
- 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
- $1,621.81 / $2,041.74 / $3,235.94
| Professional | | $1,621.81 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $2,290.87
| Facility | | $1,905.46 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $4,265.80
| Facility | | $2,041.74 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,265.80
| Professional | | $1,621.81 | $2,398.83 | $4,265.80 |
- 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
- $1,698.24 / $2,238.72 / $3,467.37
| Professional | | $1,698.24 | $2,238.72 | $3,467.37 |