- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.33 / $3,217.50 / $3,217.50
| Professional | | $2,193.33 | $3,217.50 | $3,217.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,418.01 / $9,419.70 / $11,134.41
| Facility | | $8,418.01 | $9,419.70 | $11,134.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.00 / $3,437.22 / $4,920.54
| Professional | | $531.00 | $3,437.22 | $4,920.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.00 / $3,539.00 / $7,205.00
| Facility | | $1,551.00 | $3,539.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.43 / $2,517.05 / $4,546.81
| Professional | | $1,860.43 | $2,517.05 | $4,546.81 |