- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,829.87 / $4,112.00 / $6,147.06
| Facility | | $3,829.87 | $4,112.00 | $6,147.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.75 / $600.00 / $600.00
| Professional | | $433.75 | $600.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.96 / $5,957.10 / $8,030.65
| Facility | | $5,106.96 | $5,957.10 | $8,030.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.22 / $4,112.00 / $5,756.00
| Facility | | $477.22 | $4,112.00 | $5,756.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.22 / $477.22 / $659.43
| Professional | | $477.22 | $477.22 | $659.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,252.97 / $8,937.00 / $13,282.37
| Facility | | $4,252.97 | $8,937.00 | $13,282.37 |