- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,793.73 / $4,484.33 / $20,020.00
| Facility | | $1,793.73 | $4,484.33 | $20,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.73 / $1,793.73 / $2,975.00
| Professional | | $1,793.73 | $1,793.73 | $2,975.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,421.25 / $5,170.42 / $11,020.50
| Facility | | $3,421.25 | $5,170.42 | $11,020.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,675.00 / $4,585.00 / $6,377.00
| Professional | | $3,675.00 | $4,585.00 | $6,377.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,207.00 / $4,207.00 / $8,702.00
| Facility | | $4,207.00 | $4,207.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.00 / $2,100.00 / $3,587.50
| Professional | | $1,470.00 | $2,100.00 | $3,587.50 |