- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,772.37 / $14,125.38
| Facility | | $4,466.84 | $9,772.37 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $4,897.79
| Professional | | $1,348.96 | $1,698.24 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $5,128.61
| Professional | | $933.25 | $2,187.76 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,691.53
| Professional | | $1,513.56 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $19,054.61 / $30,199.52
| Facility | | $12,022.64 | $19,054.61 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $3,890.45
| Professional | | $1,230.27 | $1,778.28 | $3,890.45 |
- 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 / $1,412.54 / $2,951.21
| Professional | | $794.33 | $1,412.54 | $2,951.21 |