- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $4,897.79
| Facility | | $2,187.76 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $4,897.79
| Professional | | $1,995.26 | $2,344.23 | $4,897.79 |
- 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
- $1,778.28 / $2,570.40 / $4,168.69
| Professional | | $1,778.28 | $2,570.40 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $2,238.72
| Facility | | $1,862.09 | $2,089.30 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $4,786.30
| Professional | | $1,949.84 | $2,630.27 | $4,786.30 |
- 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 / $2,511.89 / $4,168.69
| Professional | | $1,778.28 | $2,511.89 | $4,168.69 |