- 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
- $1,258.93 / $1,513.56 / $4,897.79
| Professional | | $1,258.93 | $1,513.56 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $4,677.35
| Professional | | $1,174.90 | $1,905.46 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,290.87
| Professional | | $1,348.96 | $1,659.59 | $2,290.87 |
- 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
- $1,318.26 / $1,905.46 / $5,888.44
| Professional | | $1,318.26 | $1,905.46 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,762.47 / $15,135.61
| Facility | | $3,630.78 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $3,548.13
| Professional | | $870.96 | $1,445.44 | $3,548.13 |