- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,467.37 / $4,897.79
| Facility | | $1,513.56 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,951.21
| Professional | | $1,479.11 | $1,737.80 | $2,951.21 |
- 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
- $1,479.11 / $1,862.09 / $2,951.21
| Professional | | $1,479.11 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,621.81 / $1,862.09
| Facility | | $1,584.89 | $1,621.81 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,238.72 / $3,467.37
| Professional | | $1,621.81 | $2,238.72 | $3,467.37 |
- 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
- $1,479.11 / $1,862.09 / $3,090.30
| Professional | | $1,479.11 | $1,862.09 | $3,090.30 |