- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $10,964.78
| Facility | | $4,466.84 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $4,466.84
| Professional | | $1,122.02 | $1,380.38 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,698.24 / $4,265.80
| Professional | | $891.25 | $1,698.24 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $2,137.96
| Professional | | $1,230.27 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $22,908.68 / $36,307.81
| Facility | | $14,454.40 | $22,908.68 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $5,370.32
| Professional | | $1,202.26 | $1,659.59 | $5,370.32 |
- 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
- $660.69 / $1,288.25 / $3,311.31
| Professional | | $660.69 | $1,288.25 | $3,311.31 |