- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,754.40 / $13,489.63
| Facility | | $3,715.35 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,951.21 / $3,548.13
| Professional | | $1,995.26 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $10,964.78
| Facility | | $3,715.35 | $3,715.35 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.76 / $8.71 / $208.93
| Professional | | $6.76 | $8.71 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $53,703.18 / $79,432.82
| Facility | | $3,548.13 | $53,703.18 | $79,432.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.55 / $4,466.84 / $10,964.78
| Professional | | $9.55 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,715.35
| Professional | | $1,548.82 | $2,187.76 | $3,715.35 |