- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $4,897.79
| Facility | | $1,995.26 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $4,466.84
| Professional | | $1,819.70 | $2,187.76 | $4,466.84 |
- 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
- $1,819.70 / $2,818.38 / $4,365.16
| Professional | | $1,819.70 | $2,818.38 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $1,995.26
| Facility | | $1,698.24 | $1,862.09 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $5,495.41
| Professional | | $1,819.70 | $2,818.38 | $5,495.41 |
- 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 / $2,187.76 / $3,715.35
| Professional | | $1,659.59 | $2,187.76 | $3,715.35 |