- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $4,897.79
| Facility | | $1,778.28 | $2,454.71 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $3,981.07
| Professional | | $1,584.89 | $1,862.09 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $25,703.96 / $35,481.34
| Facility | | $10,232.93 | $25,703.96 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,818.38 / $4,365.16
| Professional | | $1,621.81 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,659.59 / $1,778.28
| Facility | | $1,513.56 | $1,659.59 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $4,897.79
| Professional | | $1,659.59 | $2,398.83 | $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
- $1,479.11 / $1,995.26 / $3,311.31
| Professional | | $1,479.11 | $1,995.26 | $3,311.31 |