- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,835.00 / $7,249.05 / $13,582.84
| Facility | | $2,835.00 | $7,249.05 | $13,582.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,142.64 / $3,859.17 / $4,560.00
| Professional | | $3,142.64 | $3,859.17 | $4,560.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.50 / $1,326.50 / $1,326.50
| Professional | | $1,326.50 | $1,326.50 | $1,326.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.15 / $3,859.17 / $6,522.00
| Facility | | $1,513.15 | $3,859.17 | $6,522.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,707.58 / $20,123.75 / $56,346.43
| Facility | | $12,707.58 | $20,123.75 | $56,346.43 |