- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,035.30 / $14,035.30 / $18,533.40
| Facility | | $14,035.30 | $14,035.30 | $18,533.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,186.75 / $7,186.75 / $7,186.75
| Professional | | $7,186.75 | $7,186.75 | $7,186.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,424.53 / $11,769.34 / $22,196.23
| Facility | | $6,424.53 | $11,769.34 | $22,196.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,764.00 / $8,455.00 / $12,682.50
| Facility | | $6,764.00 | $8,455.00 | $12,682.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.75 / $5,495.75 / $8,455.00
| Professional | | $5,495.75 | $5,495.75 | $8,455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.50 / $2,205.00 / $5,918.50
| Professional | | $1,837.50 | $2,205.00 | $5,918.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,711.70 / $40,161.25 / $40,161.25
| Facility | | $14,711.70 | $40,161.25 | $40,161.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42,105.90 / $42,105.90 / $63,412.50
| Professional | | $42,105.90 | $42,105.90 | $63,412.50 |