- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,332.54 / $13,803.84
| Facility | | $4,466.84 | $9,332.54 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $5,495.41
| Professional | | $1,122.02 | $1,412.54 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $4,677.35
| Professional | | $1,202.26 | $1,862.09 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $2,041.74
| Professional | | $1,318.26 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,232.93 / $15,848.93
| Facility | | $6,309.57 | $10,232.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $3,162.28
| Professional | | $1,023.29 | $1,412.54 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,585.78 / $15,135.61
| Facility | | $3,630.78 | $7,585.78 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $3,311.31
| Professional | | $1,096.48 | $1,445.44 | $3,311.31 |