- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,066.80 / $6,897.54 / $25,141.80
| Facility | | $5,066.80 | $6,897.54 | $25,141.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,868.00 / $5,688.20 / $6,214.00
| Professional | | $2,868.00 | $5,688.20 | $6,214.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,003.70 / $8,548.07 / $12,015.49
| Facility | | $5,003.70 | $8,548.07 | $12,015.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.55 / $5,497.00 / $6,883.20
| Professional | | $986.55 | $5,497.00 | $6,883.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,780.00 / $4,780.00 / $4,780.00
| Facility | | $4,780.00 | $4,780.00 | $4,780.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,107.00 / $33,760.85 / $36,292.12
| Facility | | $3,107.00 | $33,760.85 | $36,292.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.60 / $2,390.00 / $6,214.00
| Professional | | $2,007.60 | $2,390.00 | $6,214.00 |