- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,772.37 / $14,125.38
| Facility | | $4,466.84 | $9,772.37 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $3,090.30
| Professional | | $851.14 | $1,122.02 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,479.11 / $3,235.94
| Professional | | $912.01 | $1,479.11 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,584.89 / $2,187.76
| Professional | | $1,071.52 | $1,584.89 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $19,054.61 / $30,199.52
| Facility | | $12,022.64 | $19,054.61 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,412.54 / $4,365.16
| Professional | | $758.58 | $1,412.54 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $21,379.62
| Facility | | $4,570.88 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $2,818.38
| Professional | | $758.58 | $1,148.15 | $2,818.38 |