- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,816.00 / $4,960.80 / $17,648.59
| Facility | | $3,816.00 | $4,960.80 | $17,648.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.00 / $4,284.00 / $4,680.00
| Professional | | $2,160.00 | $4,284.00 | $4,680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,803.04 / $6,816.96 / $11,077.92
| Facility | | $3,803.04 | $6,816.96 | $11,077.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.70 / $2,880.00 / $3,672.00
| Professional | | $657.70 | $2,880.00 | $3,672.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,851.20 / $2,851.20 / $2,851.20
| Facility | | $2,851.20 | $2,851.20 | $2,851.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,767.12 / $6,906.09 / $25,424.75
| Facility | | $3,767.12 | $6,906.09 | $25,424.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.86 / $2,868.48 / $7,224.12
| Professional | | $1,588.86 | $2,868.48 | $7,224.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,296.00 / $2,160.00 / $3,600.00
| Facility | | $1,296.00 | $2,160.00 | $3,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.00 / $2,160.00 / $5,400.00
| Professional | | $1,512.00 | $2,160.00 | $5,400.00 |