- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,388.44 / $7,943.28
| Facility | | $1,096.48 | $3,388.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,290.87
| Professional | | $1,096.48 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,709.64 / $12,302.69
| Facility | | $4,786.30 | $8,709.64 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $1,905.46
| Professional | | $1,348.96 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,380.38 / $2,089.30
| Professional | | $891.25 | $1,380.38 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $11,748.98
| Facility | | $1,148.15 | $5,248.07 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,041.74
| Professional | | $977.24 | $1,318.26 | $2,041.74 |