- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,467.37 / $4,897.79
| Facility | | $1,862.09 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $3,548.13
| Professional | | $1,778.28 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $30,199.52 / $41,686.94
| Facility | | $12,589.25 | $30,199.52 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,073.80
| Professional | | $1,862.09 | $2,630.27 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $2,238.72
| Facility | | $1,905.46 | $1,995.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $4,466.84
| Professional | | $1,949.84 | $2,884.03 | $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
- $1,862.09 / $2,344.23 / $3,801.89
| Professional | | $1,862.09 | $2,344.23 | $3,801.89 |