- 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
- $1,905.46 / $3,548.13 / $5,370.32
| Professional | | $1,905.46 | $3,548.13 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $2,290.87
| Facility | | $1,949.84 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,818.38 / $4,265.80
| Facility | | $1,995.26 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $4,365.16
| Professional | | $1,819.70 | $2,454.71 | $4,365.16 |
- 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
- $1,819.70 / $2,344.23 / $3,801.89
| Professional | | $1,819.70 | $2,344.23 | $3,801.89 |