- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $51,286.14 / $51,286.14
| Facility | | $6,309.57 | $51,286.14 | $51,286.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,309.57 / $6,918.31
| Professional | | $5,888.44 | $6,309.57 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,760.83 / $7,413.10
| Professional | | $6,025.60 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,803.84 / $14,454.40 / $32,359.37
| Facility | | $13,803.84 | $14,454.40 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $17,378.01
| Professional | | $9,772.37 | $9,772.37 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $5,888.44
| Professional | | $1,548.82 | $1,659.59 | $5,888.44 |