- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,513.67 / $3,513.67 / $6,907.00
| Facility | | $3,513.67 | $3,513.67 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.75 / $1,222.01 / $1,399.83
| Professional | | $1,198.75 | $1,222.01 | $1,399.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.66 / $1,455.93 / $2,594.38
| Professional | | $1,194.66 | $1,455.93 | $2,594.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,581.50 / $12,581.50 / $12,581.50
| Facility | | $12,581.50 | $12,581.50 | $12,581.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,530.00 / $2,530.00 / $2,530.00
| Facility | | $2,530.00 | $2,530.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.33 / $1,398.39 / $3,127.14
| Professional | | $1,087.33 | $1,398.39 | $3,127.14 |