- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,920.00 / $8,613.50 / $24,500.00
| Facility | | $3,920.00 | $8,613.50 | $24,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,043.72 / $2,364.88
| Professional | | $2,043.72 | $2,043.72 | $2,364.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,802.74 / $5,337.03 / $11,386.44
| Facility | | $4,802.74 | $5,337.03 | $11,386.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.83 / $2,275.00 / $2,275.00
| Professional | | $1,167.83 | $2,275.00 | $2,275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,271.92 / $10,984.12 / $12,807.85
| Facility | | $5,271.92 | $10,984.12 | $12,807.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,500.00 / $5,079.89 / $11,529.35
| Professional | | $3,500.00 | $5,079.89 | $11,529.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,100.00
| Professional | | $1,226.23 | $1,751.76 | $2,100.00 |