- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,897.79
| Facility | | $1,995.26 | $2,691.53 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $4,466.84
| Professional | | $1,819.70 | $2,137.96 | $4,466.84 |
- 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
- $1,737.80 / $2,754.23 / $4,265.80
| Professional | | $1,737.80 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $2,041.74
| Facility | | $1,737.80 | $1,905.46 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,890.45 / $5,128.61
| Facility | | $1,905.46 | $3,890.45 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $6,760.83
| Professional | | $1,778.28 | $2,398.83 | $6,760.83 |
- 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
- $1,659.59 / $2,290.87 / $3,801.89
| Professional | | $1,659.59 | $2,290.87 | $3,801.89 |