- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $10,964.78
| Facility | | $4,365.16 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $3,981.07
| Professional | | $1,122.02 | $1,348.96 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,698.24 / $3,981.07
| Professional | | $758.58 | $1,698.24 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $1,995.26
| Professional | | $1,122.02 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $22,387.21 / $35,481.34
| Facility | | $14,125.38 | $22,387.21 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $3,090.30
| Professional | | $977.24 | $1,412.54 | $3,090.30 |
- 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
- $812.83 / $1,202.26 / $2,511.89
| Professional | | $812.83 | $1,202.26 | $2,511.89 |