- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,398.83
| Professional | | $645.65 | $912.01 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,884.03
| Facility | | $954.99 | $954.99 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $891.25 / $1,380.38
| Professional | | $645.65 | $891.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $954.99 / $12,589.25
| Professional | | $645.65 | $954.99 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.32 / $1,230.27 / $2,238.72
| Facility | | $1.32 | $1,230.27 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $891.25 / $1,479.11
| Professional | | $645.65 | $891.25 | $1,479.11 |