- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $7,079.46
| Facility | | $3,890.45 | $3,890.45 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,890.45 / $6,760.83
| Professional | | $3,801.89 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $22,908.68 / $66,069.34
| Facility | | $12,302.69 | $22,908.68 | $66,069.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $9,332.54 / $23,988.33
| Facility | | $3,801.89 | $9,332.54 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $10,000.00 / $23,988.33
| Facility | | $1,584.89 | $10,000.00 | $23,988.33 |