- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $10,964.78
| Facility | | $1,905.46 | $1,905.46 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $10,964.78
| Professional | | $1,905.46 | $1,905.46 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $1,513.56
| Facility | | $478.63 | $602.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,168.69 / $4,786.30
| Professional | | $1,995.26 | $4,168.69 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $4,265.80 / $4,265.80
| Facility | | $64.57 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $5,495.41
| Professional | | $4,365.16 | $4,365.16 | $5,495.41 |