- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $10,964.78
| Facility | | $1,380.38 | $4,897.79 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $2,238.72
| Professional | | $1,202.26 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,454.40 / $19,498.45
| Facility | | $6,456.54 | $14,454.40 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,778.28
| Professional | | $933.25 | $1,122.02 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,258.93 / $1,380.38
| Facility | | $1,174.90 | $1,258.93 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $3,090.30
| Professional | | $1,258.93 | $1,584.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $7,762.47 / $10,964.78
| Facility | | $2,630.27 | $7,762.47 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,454.71
| Professional | | $1,122.02 | $1,479.11 | $2,454.71 |