- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,666.54 / $8,476.93 / $43,370.20
| Facility | | $2,666.54 | $8,476.93 | $43,370.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $2,666.54
| Professional | | $2,666.54 | $2,666.54 | $2,666.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,411.60 / $16,712.59 / $34,744.29
| Facility | | $7,411.60 | $16,712.59 | $34,744.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,961.31 / $9,932.68 / $13,814.77
| Professional | | $7,961.31 | $9,932.68 | $13,814.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $7,733.84
| Professional | | $3,184.52 | $4,549.32 | $7,733.84 |