- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $6,456.54 / $8,709.64
| Facility | | $1,659.59 | $6,456.54 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $75.86 / $75.86
| Professional | | $60.26 | $75.86 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $6,309.57
| Facility | | $3,162.28 | $3,162.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $7.08 / $7.08
| Professional | | $7.08 | $7.08 | $7.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $1,819.70 / $6,309.57
| Facility | | $309.03 | $1,819.70 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,673.69 / $43,651.58 / $43,651.58
| Professional | | $34,673.69 | $43,651.58 | $43,651.58 |