- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $21,379.62
| Facility | | $1,548.82 | $1,548.82 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $21,379.62
| Professional | | $1,548.82 | $1,548.82 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $426.58 / $1,071.52
| Facility | | $338.84 | $426.58 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,388.44 / $3,981.07
| Professional | | $1,862.09 | $3,388.44 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $50,118.72
| Facility | | $64.57 | $64.57 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,981.07 / $4,786.30
| Professional | | $3,801.89 | $3,981.07 | $4,786.30 |