- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,128.61 / $12,022.64
| Facility | | $1,737.80 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,778.28 / $2,951.21
| Professional | | $1,174.90 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $10,471.29 / $20,892.96
| Facility | | $4,466.84 | $10,471.29 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $2,089.30 / $5,623.41
| Professional | | $630.96 | $2,089.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $11,748.98
| Facility | | $6,456.54 | $6,456.54 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $16,982.44 / $16,982.44
| Professional | | $1,380.38 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $8,912.51 / $20,417.38
| Facility | | $2,951.21 | $8,912.51 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,511.89 / $5,248.07
| Professional | | $1,479.11 | $2,511.89 | $5,248.07 |