- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,562.50 / $21,562.50 / $21,562.50
| Facility | | $21,562.50 | $21,562.50 | $21,562.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.21 / $2,161.02 / $3,075.00
| Professional | | $2,044.21 | $2,161.02 | $3,075.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,920.30 / $4,416.75 / $4,612.50
| Facility | | $2,920.30 | $4,416.75 | $4,612.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.63 / $2,812.50 / $2,812.50
| Professional | | $2,390.63 | $2,812.50 | $2,812.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,081.47 / $5,081.47 / $9,953.03
| Facility | | $5,081.47 | $5,081.47 | $9,953.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.94 / $4,976.29 / $10,151.45
| Professional | | $1,658.94 | $4,976.29 | $10,151.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.15 / $2,250.00 / $4,211.95
| Professional | | $1,460.15 | $2,250.00 | $4,211.95 |