- 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
- $1,096.48 / $1,288.25 / $4,786.30
| Professional | | $1,096.48 | $1,288.25 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $4,570.88
| Professional | | $1,148.15 | $1,905.46 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $1,995.26
| Professional | | $1,174.90 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,125.38 / $21,877.62 / $38,904.51
| Facility | | $14,125.38 | $21,877.62 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $5,370.32
| Professional | | $1,148.15 | $1,621.81 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,120.11 / $21,379.62
| Facility | | $4,570.88 | $9,120.11 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,445.44 / $2,884.03
| Professional | | $794.33 | $1,445.44 | $2,884.03 |