- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,674.14 / $5,674.14 / $7,715.84
| Facility | | $5,674.14 | $5,674.14 | $7,715.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,674.14 / $5,674.14 / $5,674.14
| Professional | | $5,674.14 | $5,674.14 | $5,674.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,674.67 / $6,533.38 / $9,240.57
| Facility | | $2,674.67 | $6,533.38 | $9,240.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.00 / $4,044.92 / $5,056.14
| Professional | | $2,816.00 | $4,044.92 | $5,056.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,112.00 / $2,816.00 / $3,520.00
| Facility | | $2,112.00 | $2,816.00 | $3,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.00 / $3,520.00 / $3,520.00
| Professional | | $2,288.00 | $3,520.00 | $3,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.00 / $1,760.00 / $3,520.00
| Professional | | $1,584.00 | $1,760.00 | $3,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,124.80 / $16,720.00 / $16,720.00
| Facility | | $6,124.80 | $16,720.00 | $16,720.00 |