- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,101.46 / $2,101.46 / $14,237.10
| Facility | | $2,101.46 | $2,101.46 | $14,237.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.84 / $2,500.00 / $2,500.00
| Professional | | $2,398.84 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,002.09 / $4,105.35
| Professional | | $3,002.09 | $3,002.09 | $4,105.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,456.00 / $7,395.65 / $17,117.33
| Facility | | $5,456.00 | $7,395.65 | $17,117.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,341.63 / $3,002.09 / $3,632.53
| Facility | | $2,341.63 | $3,002.09 | $3,632.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,501.05 / $3,002.09
| Professional | | $1,260.88 | $1,501.05 | $3,002.09 |