- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,561.54 / $8,561.54 / $8,561.54
| Facility | | $8,561.54 | $8,561.54 | $8,561.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.52 / $2,245.06 / $2,457.42
| Professional | | $2,017.52 | $2,245.06 | $2,457.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,410.84 / $14,410.84 / $14,410.84
| Facility | | $14,410.84 | $14,410.84 | $14,410.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.32 / $1,820.32 / $15,108.62
| Professional | | $1,820.32 | $1,820.32 | $15,108.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,695.30 / $3,695.30 / $4,427.39
| Professional | | $3,695.30 | $3,695.30 | $4,427.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,377.62 / $4,377.62 / $5,150.14
| Professional | | $4,377.62 | $4,377.62 | $5,150.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,033.86 / $3,033.86 / $3,033.86
| Professional | | $3,033.86 | $3,033.86 | $3,033.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,410.84 / $14,410.84 / $14,410.84
| Facility | | $14,410.84 | $14,410.84 | $14,410.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.32 / $1,820.32 / $15,108.62
| Professional | | $1,820.32 | $1,820.32 | $15,108.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.32 / $1,941.67 / $6,381.69
| Professional | | $1,820.32 | $1,941.67 | $6,381.69 |