- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,314.16 / $8,100.29 / $12,516.60
| Facility | | $4,314.16 | $8,100.29 | $12,516.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.00 / $3,410.40 / $3,920.00
| Professional | | $2,940.00 | $3,410.40 | $3,920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,487.50 / $4,487.50 / $4,487.50
| Professional | | $4,487.50 | $4,487.50 | $4,487.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,187.55 / $5,880.42 / $8,888.76
| Facility | | $3,187.55 | $5,880.42 | $8,888.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.40 / $3,920.00 / $5,273.62
| Facility | | $3,214.40 | $3,920.00 | $5,273.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.40 / $2,352.00 / $19,521.59
| Professional | | $1,646.40 | $2,352.00 | $19,521.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.00 / $2,352.00 / $5,880.00
| Professional | | $1,764.00 | $2,352.00 | $5,880.00 |