- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,895.50 / $5,303.02 / $19,329.80
| Facility | | $3,895.50 | $5,303.02 | $19,329.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $4,373.25 / $4,777.50
| Professional | | $2,205.00 | $4,373.25 | $4,777.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,979.29 / $7,176.91 / $11,308.71
| Facility | | $3,979.29 | $7,176.91 | $11,308.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.09 / $597.91 / $663.68
| Professional | | $547.09 | $597.91 | $663.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,675.00 / $3,675.00 / $3,675.00
| Facility | | $3,675.00 | $3,675.00 | $3,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,388.75 / $2,959.66 / $27,902.18
| Facility | | $2,388.75 | $2,959.66 | $27,902.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $4,777.50
| Professional | | $1,543.50 | $2,205.00 | $4,777.50 |