- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.00 / $2,747.52 / $8,845.20
| Facility | | $2,430.00 | $2,747.52 | $8,845.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.00 / $2,527.19 / $3,078.00
| Professional | | $2,430.00 | $2,527.19 | $3,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.80 / $4,276.80 / $6,382.80
| Professional | | $1,684.80 | $4,276.80 | $6,382.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,852.31 / $6,669.81 / $11,568.87
| Facility | | $1,852.31 | $6,669.81 | $11,568.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,240.00 / $3,240.00 / $15,616.80
| Professional | | $3,240.00 | $3,240.00 | $15,616.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,637.60 / $15,390.00 / $15,390.00
| Facility | | $5,637.60 | $15,390.00 | $15,390.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,200.00 / $16,200.00 / $24,300.00
| Professional | | $16,200.00 | $16,200.00 | $24,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.80 / $1,944.00 / $3,240.00
| Professional | | $1,360.80 | $1,944.00 | $3,240.00 |