- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.40 / $12,997.30 / $17,040.30
| Facility | | $2,480.40 | $12,997.30 | $17,040.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.40 / $2,480.40 / $2,480.40
| Professional | | $2,480.40 | $2,480.40 | $2,480.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,646.54 / $6,835.96 / $21,425.60
| Facility | | $6,646.54 | $6,835.96 | $21,425.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,573.04 / $8,053.72 / $16,550.56
| Professional | | $3,573.04 | $8,053.72 | $16,550.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,776.00 / $8,942.40 / $9,331.20
| Facility | | $7,776.00 | $8,942.40 | $9,331.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,000.79 / $7,857.69 / $9,320.64
| Professional | | $7,000.79 | $7,857.69 | $9,320.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.92 / $3,265.92 / $4,665.60
| Professional | | $3,265.92 | $3,265.92 | $4,665.60 |