- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,467.37 / $4,897.79
| Facility | | $1,905.46 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,715.35
| Professional | | $1,862.09 | $2,187.76 | $3,715.35 |
- 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
- $1,905.46 / $2,511.89 / $3,890.45
| Professional | | $1,905.46 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $2,344.23
| Facility | | $1,995.26 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,951.21 / $4,570.88
| Professional | | $2,041.74 | $2,951.21 | $4,570.88 |
- 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
- $1,905.46 / $2,398.83 / $3,890.45
| Professional | | $1,905.46 | $2,398.83 | $3,890.45 |