- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $8,709.64
| Facility | | $2,691.53 | $2,691.53 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $7,244.36
| Professional | | $2,691.53 | $2,691.53 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $14,791.08 / $23,988.33
| Facility | | $8,317.64 | $14,791.08 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $977.24
| Professional | | $891.25 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,511.38 / $57,543.99
| Facility | | $4,897.79 | $8,511.38 | $57,543.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,760.83 / $7,585.78
| Facility | | $3,162.28 | $6,760.83 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $10,715.19
| Professional | | $3,162.28 | $3,801.89 | $10,715.19 |