- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $7,762.47
| Facility | | $1,819.70 | $1,819.70 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,344.23
| Professional | | $1,148.15 | $1,819.70 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,606.93 / $16,595.87
| Facility | | $3,630.78 | $6,606.93 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,090.30 / $26,915.35
| Facility | | $1,905.46 | $3,090.30 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,235.94 / $7,762.47
| Professional | | $1,905.46 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $16,218.10 / $53,703.18
| Facility | | $4,897.79 | $16,218.10 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $6,165.95
| Professional | | $1,819.70 | $2,884.03 | $6,165.95 |