- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,405.00 / $5,522.00 / $9,901.50
| Facility | | $2,405.00 | $5,522.00 | $9,901.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,074.50 / $18,028.10 / $18,028.12
| Professional | | $8,074.50 | $18,028.10 | $18,028.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,441.00 / $11,083.00 / $22,940.50
| Facility | | $8,441.00 | $11,083.00 | $22,940.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.03 / $233.03 / $233.03
| Professional | | $233.03 | $233.03 | $233.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,752.73 / $14,752.73 / $16,148.71
| Facility | | $14,752.73 | $14,752.73 | $16,148.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,350.00
| Professional | | $1,350.00 | $1,350.00 | $1,350.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,873.00 / $10,317.00 / $19,962.00
| Facility | | $4,873.00 | $10,317.00 | $19,962.00 |