- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,305.15 / $17,471.40 / $26,996.80
| Facility | | $9,305.15 | $17,471.40 | $26,996.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,341.25 / $6,341.25 / $8,455.00
| Professional | | $6,341.25 | $6,341.25 | $8,455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,568.75 / $10,568.75 / $10,568.75
| Professional | | $10,568.75 | $10,568.75 | $10,568.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,474.22 / $13,849.29 / $19,171.39
| Facility | | $7,474.22 | $13,849.29 | $19,171.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,764.00 / $8,455.00 / $11,374.60
| Facility | | $6,764.00 | $8,455.00 | $11,374.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $42,105.90
| Professional | | $1,543.50 | $2,205.00 | $42,105.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $5,512.50
| Professional | | $1,543.50 | $2,205.00 | $5,512.50 |