- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $14,791.08
| Facility | | $7,943.28 | $7,943.28 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,918.31 / $10,715.19
| Professional | | $5,888.44 | $6,918.31 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $11,481.54 / $28,840.32
| Facility | | $6,309.57 | $11,481.54 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,309.57 / $6,309.57
| Professional | | $6,025.60 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $12,882.50
| Professional | | $10,232.93 | $10,232.93 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $20,417.38
| Facility | | $7,943.28 | $7,943.28 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $8,912.51 / $11,481.54
| Professional | | $7,943.28 | $8,912.51 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,232.93 / $10,232.93 / $10,232.93
| Professional | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,511.38 / $8,511.38
| Facility | | $5,128.61 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,715.35
| Professional | | $1,548.82 | $2,187.76 | $3,715.35 |