- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,853.35 / $4,790.64 / $4,790.64
| Facility | | $3,853.35 | $4,790.64 | $4,790.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.05 / $4,790.64 / $4,790.64
| Professional | | $2,947.05 | $4,790.64 | $4,790.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $744.10 / $892.92 / $1,249.31
| Facility | | $744.10 | $892.92 | $1,249.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $422.50
| Facility | | $422.50 | $422.50 | $422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $4,550.34 / $8,385.94
| Professional | | $422.50 | $4,550.34 | $8,385.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.84 / $4,790.64 / $5,269.70
| Facility | | $739.84 | $4,790.64 | $5,269.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,709.67 / $6,940.00 / $6,940.00
| Professional | | $4,709.67 | $6,940.00 | $6,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.71 / $3,055.76 / $5,090.08
| Professional | | $2,342.71 | $3,055.76 | $5,090.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,030.03 / $30,361.48 / $30,361.48
| Facility | | $8,030.03 | $30,361.48 | $30,361.48 |