- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,592.00 / $5,546.40 / $8,844.50
| Facility | | $4,592.00 | $5,546.40 | $8,844.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,718.80 / $5,546.40 / $10,428.29
| Professional | | $4,718.80 | $5,546.40 | $10,428.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,439.08 / $7,591.82 / $21,232.89
| Facility | | $2,439.08 | $7,591.82 | $21,232.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,505.30 / $6,671.16 / $11,572.40
| Professional | | $4,505.30 | $6,671.16 | $11,572.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,504.54 / $6,037.46 / $8,051.13
| Professional | | $5,504.54 | $6,037.46 | $8,051.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.00 / $3,629.00 / $10,000.00
| Facility | | $1,036.00 | $3,629.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,661.74 / $6,064.80 / $13,109.54
| Professional | | $4,661.74 | $6,064.80 | $13,109.54 |