- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,566.05 / $1,566.05 / $1,566.05
| Facility | | $1,566.05 | $1,566.05 | $1,566.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.66 / $1,566.05 / $1,566.05
| Professional | | $905.66 | $1,566.05 | $1,566.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,931.69 / $9,625.46 / $12,949.34
| Facility | | $7,931.69 | $9,625.46 | $12,949.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.62 / $1,194.00 / $1,408.92
| Professional | | $871.62 | $1,194.00 | $1,408.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,668.00 / $14,352.00 / $15,143.00
| Facility | | $13,668.00 | $14,352.00 | $15,143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.04 / $1,212.53 / $3,370.73
| Professional | | $966.04 | $1,212.53 | $3,370.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.00 / $4,852.00 / $9,624.00
| Facility | | $1,404.00 | $4,852.00 | $9,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.07 / $960.56 / $1,600.16
| Professional | | $760.07 | $960.56 | $1,600.16 |