- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,817.30 / $7,604.10 / $16,683.68
| Facility | | $3,817.30 | $7,604.10 | $16,683.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $1,545.58
| Professional | | $1,545.58 | $1,545.58 | $1,545.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.62 / $27.53 / $66.79
| Facility | | $18.62 | $27.53 | $66.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.79 / $1,476.79 / $1,476.79
| Facility | | $1,476.79 | $1,476.79 | $1,476.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,638.31 / $4,690.97
| Facility | | $1,545.58 | $1,638.31 | $4,690.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,545.58 / $1,545.58 / $2,472.92
| Facility | | $1,545.58 | $1,545.58 | $2,472.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.66 / $660.66 / $660.66
| Professional | | $660.66 | $660.66 | $660.66 |