- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,677.35
| Professional | | $3,162.28 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,365.16 / $7,943.28
| Facility | | $1,659.59 | $4,365.16 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $3,630.78
| Professional | | $1,737.80 | $2,238.72 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,265.80 / $9,549.93
| Facility | | $1,778.28 | $4,265.80 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42,657.95 / $42,657.95 / $42,657.95
| Professional | | $42,657.95 | $42,657.95 | $42,657.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,089.30 / $5,248.07
| Facility | | $831.76 | $2,089.30 | $5,248.07 |