- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,859.17 / $9,265.39 / $22,451.68
| Facility | | $3,859.17 | $9,265.39 | $22,451.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $9,251.04
| Professional | | $3,859.17 | $3,859.17 | $9,251.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,859.17 / $3,859.17 / $4,631.00
| Facility | | $3,859.17 | $3,859.17 | $4,631.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32,686.66 / $32,686.66 / $44,419.37
| Facility | | $32,686.66 | $32,686.66 | $44,419.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $5,409.35 / $5,409.35
| Facility | | $100.00 | $5,409.35 | $5,409.35 |