- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $4,897.79
| Facility | | $2,041.74 | $2,630.27 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $3,467.37
| Professional | | $1,698.24 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $19,054.61 / $26,302.68
| Facility | | $9,549.93 | $19,054.61 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $3,801.89
| Professional | | $1,698.24 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $2,041.74
| Facility | | $1,737.80 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $4,466.84
| Professional | | $1,737.80 | $2,344.23 | $4,466.84 |
- 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 / $2,089.30 / $3,548.13
| Professional | | $1,659.59 | $2,089.30 | $3,548.13 |