- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.51 / $1,395.00 / $12,759.45
| Facility | | $1,083.51 | $1,395.00 | $12,759.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55,249.45 / $64,999.35 / $64,999.35
| Professional | | $55,249.45 | $64,999.35 | $64,999.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.16 / $2,117.16 / $2,117.16
| Professional | | $2,117.16 | $2,117.16 | $2,117.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55,249.45 / $55,249.45 / $55,249.45
| Professional | | $55,249.45 | $55,249.45 | $55,249.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,293.50 / $6,293.50 / $6,293.50
| Facility | | $6,293.50 | $6,293.50 | $6,293.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.16 / $2,117.16 / $2,117.16
| Professional | | $2,117.16 | $2,117.16 | $2,117.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.00 / $650.00 / $3,742.00
| Facility | | $162.00 | $650.00 | $3,742.00 |