- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,832.64 / $4,270.66 / $25,965.60
| Facility | | $3,832.64 | $4,270.66 | $25,965.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,270.66 / $4,270.66 / $4,763.42
| Professional | | $4,270.66 | $4,270.66 | $4,763.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,750.16 / $1,750.16 / $1,750.16
| Facility | | $1,750.16 | $1,750.16 | $1,750.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,748.96 / $7,555.78
| Professional | | $5,475.20 | $5,748.96 | $7,555.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,950.62 / $13,488.16 / $31,218.50
| Facility | | $9,950.62 | $13,488.16 | $31,218.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,270.66 / $5,475.20 / $6,918.47
| Facility | | $4,270.66 | $5,475.20 | $6,918.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,122.94 / $4,985.77
| Professional | | $2,299.58 | $3,122.94 | $4,985.77 |