- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,904.75 / $4,841.25 / $12,393.60
| Facility | | $2,904.75 | $4,841.25 | $12,393.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,904.75 / $3,020.94 / $3,679.35
| Professional | | $2,904.75 | $3,020.94 | $3,679.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.96 / $5,422.20 / $7,629.81
| Professional | | $2,013.96 | $5,422.20 | $7,629.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,214.21 / $9,351.66 / $12,143.20
| Facility | | $2,214.21 | $9,351.66 | $12,143.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.47 / $2,576.82 / $6,597.17
| Professional | | $1,729.47 | $2,576.82 | $6,597.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,739.02 / $18,396.75 / $18,396.75
| Facility | | $6,739.02 | $18,396.75 | $18,396.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,365.00 / $19,365.00 / $29,047.50
| Professional | | $19,365.00 | $19,365.00 | $29,047.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $2,323.80 / $3,873.00
| Professional | | $1,626.66 | $2,323.80 | $3,873.00 |