- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,754.40
| Facility | | $4,897.79 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $4,365.16
| Professional | | $1,445.44 | $2,137.96 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,748.98 / $12,302.69
| Professional | | $11,220.18 | $11,748.98 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,754.40 / $6,918.31
| Facility | | $2,344.23 | $5,754.40 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $2,951.21
| Professional | | $1,096.48 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $10,232.93 / $25,703.96
| Facility | | $4,677.35 | $10,232.93 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,344.23 / $3,162.28
| Professional | | $1,445.44 | $2,344.23 | $3,162.28 |