- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,467.37 / $4,897.79
| Facility | | $1,659.59 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,905.46 / $3,162.28
| Professional | | $1,621.81 | $1,905.46 | $3,162.28 |
- 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
- $1,659.59 / $2,089.30 / $3,235.94
| Professional | | $1,659.59 | $2,089.30 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,778.28 / $2,041.74
| Facility | | $1,737.80 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $3,981.07
| Professional | | $1,778.28 | $2,511.89 | $3,981.07 |
- 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 / $3,388.44
| Professional | | $1,659.59 | $2,089.30 | $3,388.44 |