- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,025.60 / $10,715.19
| Facility | | $4,365.16 | $6,025.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,238.72
| Professional | | $977.24 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.35 / $50,118.72 / $69,183.10
| Facility | | $26,915.35 | $50,118.72 | $69,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,981.07
| Professional | | $1,348.96 | $1,905.46 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,235.94
| Professional | | $1,047.13 | $1,513.56 | $3,235.94 |