- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $6,606.93
| Facility | | $1,096.48 | $1,096.48 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,778.28
| Professional | | $1,096.48 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $16,218.10 / $41,686.94
| Facility | | $9,120.11 | $16,218.10 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $5,248.07
| Professional | | $3,467.37 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,659.59 / $12,022.64
| Facility | | $912.01 | $1,659.59 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,309.57 / $12,589.25
| Facility | | $2,951.21 | $6,309.57 | $12,589.25 |