- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,632.64 / $6,632.64 / $9,555.00
| Facility | | $6,632.64 | $6,632.64 | $9,555.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.50 / $3,454.50 / $3,454.50
| Professional | | $2,572.50 | $3,454.50 | $3,454.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,332.50 / $14,332.50 / $14,332.50
| Facility | | $14,332.50 | $14,332.50 | $14,332.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.76 / $7,166.25 / $7,882.88
| Facility | | $4,421.76 | $7,166.25 | $7,882.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,675.00 / $3,675.00 / $4,410.00
| Professional | | $3,675.00 | $3,675.00 | $4,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,675.00
| Professional | | $30.00 | $30.00 | $3,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,512.50 / $7,350.00 / $13,230.00
| Facility | | $5,512.50 | $7,350.00 | $13,230.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,492.40 / $5,492.40 / $5,676.27
| Professional | | $5,492.40 | $5,492.40 | $5,676.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $1,543.50 / $4,226.25
| Professional | | $1,543.50 | $1,543.50 | $4,226.25 |