- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $11,748.98
| Facility | | $4,365.16 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $3,630.78
| Professional | | $1,047.13 | $1,258.93 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $3,890.45
| Professional | | $1,122.02 | $1,659.59 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $1,905.46
| Professional | | $1,122.02 | $1,380.38 | $1,905.46 |
- 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
- $1,000.00 / $1,584.89 / $5,011.87
| Professional | | $1,000.00 | $1,584.89 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $8,709.64 / $21,379.62
| Facility | | $3,890.45 | $8,709.64 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $3,019.95
| Professional | | $912.01 | $1,258.93 | $3,019.95 |