- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,111.64 / $4,111.64 / $6,907.00
| Facility | | $4,111.64 | $4,111.64 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.35 / $1,599.86 / $1,599.86
| Professional | | $1,435.35 | $1,599.86 | $1,599.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,271.70 / $15,271.70 / $15,271.70
| Facility | | $15,271.70 | $15,271.70 | $15,271.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.67 / $1,739.35 / $3,093.58
| Professional | | $1,415.67 | $1,739.35 | $3,093.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,282.36 / $14,282.36 / $14,282.36
| Facility | | $14,282.36 | $14,282.36 | $14,282.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,530.00
| Facility | | $2,000.00 | $2,000.00 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.74 / $1,734.85 / $3,722.37
| Professional | | $1,376.74 | $1,734.85 | $3,722.37 |