- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $11,481.54
| Facility | | $2,398.83 | $2,754.23 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $199.53 / $489.78
| Professional | | $158.49 | $199.53 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $8,912.51
| Facility | | $5,011.87 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $380.19 / $549.54
| Professional | | $158.49 | $380.19 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $398.11 / $588.84
| Professional | | $223.87 | $398.11 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $295.12 / $489.78
| Professional | | $177.83 | $295.12 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $331.13 / $588.84
| Professional | | $204.17 | $331.13 | $588.84 |