- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,128.61 / $8,511.38
| Facility | | $1,445.44 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $2,818.38 / $8,511.38
| Professional | | $213.80 | $2,818.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Professional | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $8,912.51 / $14,125.38
| Facility | | $5,754.40 | $8,912.51 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $6,025.60 / $10,232.93
| Facility | | $1,621.81 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Professional | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,754.40 / $10,715.19
| Facility | | $1,621.81 | $5,754.40 | $10,715.19 |