- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $6,606.93
| Facility | | $4,073.80 | $4,897.79 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $4,786.30 / $6,760.83
| Professional | | $630.96 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $10,715.19
| Facility | | $10,715.19 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $10,715.19 / $11,220.18
| Professional | | $6,309.57 | $10,715.19 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,073.80 / $6,606.93
| Facility | | $1,621.81 | $4,073.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,905.46 / $6,606.93
| Professional | | $645.65 | $1,905.46 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $10,232.93 / $19,952.62
| Facility | | $5,370.32 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $691.83 / $12,882.50
| Professional | | $489.78 | $691.83 | $12,882.50 |