- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,821.91 / $17,975.75 / $27,453.76
| Facility | | $15,821.91 | $17,975.75 | $27,453.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,126.71 / $15,821.91 / $19,968.25
| Professional | | $14,126.71 | $15,821.91 | $19,968.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,325.37 / $25,517.54 / $32,261.47
| Facility | | $21,325.37 | $25,517.54 | $32,261.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,087.50 / $16,087.50 / $16,087.50
| Professional | | $16,087.50 | $16,087.50 | $16,087.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |