- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.08 / $1,120.08 / $11,009.00
| Facility | | $1,120.08 | $1,120.08 | $11,009.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.26 / $1,120.08 / $1,120.08
| Professional | | $979.26 | $1,120.08 | $1,120.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,540.35 / $26,444.67 / $45,003.43
| Facility | | $15,540.35 | $26,444.67 | $45,003.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $2,097.00 / $3,954.00
| Facility | | $1,751.00 | $2,097.00 | $3,954.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.13 / $2,598.42 / $5,232.68
| Professional | | $1,545.13 | $2,598.42 | $5,232.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.13 / $2,473.55 / $4,889.62
| Professional | | $1,545.13 | $2,473.55 | $4,889.62 |