- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $4,897.79
| Facility | | $1,513.56 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $3,388.44
| Professional | | $1,380.38 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $47,863.01 / $97,723.72
| Facility | | $22,908.68 | $47,863.01 | $97,723.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $3,801.89
| Professional | | $1,380.38 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $1,548.82
| Facility | | $1,288.25 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $4,265.80
| Professional | | $1,380.38 | $2,137.96 | $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
- $1,258.93 / $1,698.24 / $2,818.38
| Professional | | $1,258.93 | $1,698.24 | $2,818.38 |