- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,466.84 / $15,848.93
| Facility | | $2,398.83 | $4,466.84 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $3,548.13
| Professional | | $1,202.26 | $1,445.44 | $3,548.13 |
- 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
- $1,047.13 / $2,238.72 / $3,388.44
| Professional | | $1,047.13 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $4,168.69
| Professional | | $1,513.56 | $2,511.89 | $4,168.69 |
- 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
- $1,258.93 / $2,137.96 / $3,801.89
| Professional | | $1,258.93 | $2,137.96 | $3,801.89 |
- 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
- $1,621.81 / $2,398.83 / $4,466.84
| Professional | | $1,621.81 | $2,398.83 | $4,466.84 |