- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $12,589.25 / $12,589.25
| Facility | | $6,918.31 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,918.31 / $7,244.36
| Professional | | $5,888.44 | $6,918.31 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Facility | | $11,481.54 | $11,481.54 | $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
- $7,079.46 / $13,489.63 / $25,118.86
| Facility | | $7,079.46 | $13,489.63 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40,738.03 / $40,738.03 / $40,738.03
| Professional | | $40,738.03 | $40,738.03 | $40,738.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $4,570.88
| Professional | | $1,548.82 | $1,819.70 | $4,570.88 |