- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36,307.81 / $36,307.81 / $36,307.81
| Facility | | $36,307.81 | $36,307.81 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $3,630.78
| Professional | | $1,621.81 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $3,090.30
| Professional | | $2,290.87 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $645.65
| Facility | | $512.86 | $512.86 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $4,677.35
| Professional | | $1,737.80 | $2,344.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $4,265.80
| Professional | | $2,089.30 | $2,398.83 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $4,073.80
| Facility | | $1,949.84 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $4,168.69
| Professional | | $1,479.11 | $2,187.76 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,511.89 / $3,235.94
| Professional | | $1,659.59 | $2,511.89 | $3,235.94 |