- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,346.00 / $3,728.40 / $22,668.70
| Facility | | $3,346.00 | $3,728.40 | $22,668.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,728.40 / $3,728.40 / $3,824.00
| Professional | | $3,728.40 | $3,728.40 | $3,824.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,780.00 / $5,019.00 / $6,596.40
| Professional | | $4,780.00 | $5,019.00 | $6,596.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,185.14 / $9,693.84 / $27,254.60
| Facility | | $3,185.14 | $9,693.84 | $27,254.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.40 / $4,780.00 / $5,783.80
| Facility | | $3,728.40 | $4,780.00 | $5,783.80 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $2,007.60 / $2,868.00 / $4,780.00
| Professional | | $2,007.60 | $2,868.00 | $4,780.00 |