- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,710.00 / $5,050.50 / $18,409.30
| Facility | | $3,710.00 | $5,050.50 | $18,409.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $4,165.00 / $4,550.00
| Professional | | $2,100.00 | $4,165.00 | $4,550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,663.80 / $6,259.05 / $8,797.95
| Facility | | $3,663.80 | $6,259.05 | $8,797.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.55 / $923.50 / $4,512.47
| Professional | | $814.55 | $923.50 | $4,512.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,500.00 / $3,500.00 / $3,500.00
| Facility | | $3,500.00 | $3,500.00 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,662.47 / $6,714.64 / $24,718.71
| Facility | | $3,662.47 | $6,714.64 | $24,718.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $1,750.00 / $4,550.00
| Professional | | $1,470.00 | $1,750.00 | $4,550.00 |