- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $6,025.60 / $20,892.96
| Facility | | $2,041.74 | $6,025.60 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,691.53
| Professional | | $1,148.15 | $1,380.38 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $15,848.93 / $28,183.83
| Facility | | $9,332.54 | $15,848.93 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,454.71
| Professional | | $1,258.93 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $4,365.16
| Facility | | $794.33 | $794.33 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,570.40
| Professional | | $1,230.27 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $5,248.07
| Professional | | $1,202.26 | $1,698.24 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,288.25
| Professional | | $1,202.26 | $1,202.26 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $13,489.63 / $33,113.11
| Facility | | $3,890.45 | $13,489.63 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,818.38
| Professional | | $1,258.93 | $1,778.28 | $2,818.38 |