- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,585.78 / $7,585.78
| Facility | | $4,073.80 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,073.80 / $4,677.35
| Professional | | $3,715.35 | $4,073.80 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $7,943.28 / $15,135.61
| Facility | | $4,168.69 | $7,943.28 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Professional | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $6,309.57
| Professional | | $2,089.30 | $2,238.72 | $6,309.57 |