- 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 / $29,512.09 / $39,810.72
| Facility | | $12,589.25 | $29,512.09 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $3,019.95
| Professional | | $1,445.44 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,659.59 / $1,862.09
| Facility | | $1,479.11 | $1,659.59 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $3,388.44
| Professional | | $1,513.56 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,623.41 / $12,022.64
| Facility | | $1,412.54 | $5,623.41 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,819.70 / $3,090.30
| Professional | | $1,348.96 | $1,819.70 | $3,090.30 |