- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,572.50 / $2,866.50 / $17,428.30
| Facility | | $2,572.50 | $2,866.50 | $17,428.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,866.50 / $2,866.50 / $3,197.25
| Professional | | $2,866.50 | $2,866.50 | $3,197.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,675.00 / $3,675.00 / $5,025.56
| Professional | | $3,675.00 | $3,675.00 | $5,025.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.83 / $7,452.90 / $20,954.12
| Facility | | $2,448.83 | $7,452.90 | $20,954.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,866.50 / $3,675.00 / $4,630.50
| Facility | | $2,866.50 | $3,675.00 | $4,630.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,307.50 / $3,675.00 / $3,675.00
| Facility | | $3,307.50 | $3,675.00 | $3,675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,096.15 / $3,675.00
| Professional | | $1,543.50 | $2,096.15 | $3,675.00 |