- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $11,748.98
| Facility | | $4,365.16 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $5,370.32
| Professional | | $1,659.59 | $1,949.84 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $19,498.45 / $21,379.62
| Facility | | $16,595.87 | $19,498.45 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $6,760.83
| Professional | | $1,819.70 | $2,818.38 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,388.44
| Professional | | $1,819.70 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $7,762.47
| Professional | | $1,698.24 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,888.44 / $10,471.29
| Facility | | $1,698.24 | $5,888.44 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $4,265.80
| Professional | | $1,202.26 | $2,187.76 | $4,265.80 |