- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $10,497.60
| Facility | | $2,480.40 | $2,480.40 | $10,497.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $4,665.60
| Professional | | $2,480.40 | $2,480.40 | $4,665.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.09 / $597.91 / $663.68
| Professional | | $547.09 | $597.91 | $663.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,776.00 / $7,776.00 / $7,776.00
| Facility | | $7,776.00 | $7,776.00 | $7,776.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,136.82 / $14,917.34 / $54,920.62
| Facility | | $8,136.82 | $14,917.34 | $54,920.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,390.34 / $3,635.33 / $30,106.95
| Professional | | $3,390.34 | $3,635.33 | $30,106.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.92 / $4,433.10 / $10,108.79
| Professional | | $3,265.92 | $4,433.10 | $10,108.79 |