- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $6,456.54
| Facility | | $1,995.26 | $2,754.23 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $1,659.59
| Professional | | $1,148.15 | $1,445.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $5,248.07
| Facility | | $1,737.80 | $1,737.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $851.14 / $1,698.24
| Professional | | $426.58 | $851.14 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $25,703.96 / $38,018.94
| Facility | | $1,698.24 | $25,703.96 | $38,018.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $6,918.31
| Facility | | $1,148.15 | $1,148.15 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,137.96 / $5,248.07
| Professional | | $1,122.02 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,737.80
| Professional | | $741.31 | $1,047.13 | $1,737.80 |