- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,890.45 / $15,848.93
| Facility | | $1,348.96 | $3,890.45 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $2,951.21
| Professional | | $1,096.48 | $1,258.93 | $2,951.21 |
- 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
- $1,096.48 / $2,187.76 / $3,162.28
| Professional | | $1,096.48 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $2,344.23 / $3,630.78
| Professional | | $467.74 | $2,344.23 | $3,630.78 |
- 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
- $1,230.27 / $1,995.26 / $3,388.44
| Professional | | $1,230.27 | $1,995.26 | $3,388.44 |
- 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
- $1,412.54 / $2,137.96 / $3,801.89
| Professional | | $1,412.54 | $2,137.96 | $3,801.89 |