- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,511.38 / $16,218.10
| Facility | | $4,570.88 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $2,398.83
| Professional | | $1,258.93 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $17,378.01 / $36,307.81
| Facility | | $9,120.11 | $17,378.01 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $1,995.26
| Professional | | $1,230.27 | $1,659.59 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $489.78 / $724.44
| Professional | | $478.63 | $489.78 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $13,489.63 / $19,498.45
| Facility | | $5,888.44 | $13,489.63 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $4,897.79
| Professional | | $1,698.24 | $2,187.76 | $4,897.79 |