- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $4,466.84
| Facility | | $1,148.15 | $1,819.70 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,041.74
| Professional | | $1,096.48 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $25.12 / $50.12
| Professional | | $21.38 | $25.12 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $16,218.10 / $35,481.34
| Facility | | $1,819.70 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $4,073.80
| Professional | | $1,737.80 | $2,187.76 | $4,073.80 |