- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $14,791.08
| Facility | | $6,760.83 | $6,760.83 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $6,760.83
| Professional | | $3,630.78 | $4,897.79 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $11,220.18 / $18,197.01
| Facility | | $8,317.64 | $11,220.18 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $6,606.93
| Professional | | $1,621.81 | $2,398.83 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $38,904.51
| Facility | | $4,365.16 | $4,365.16 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $12,589.25 / $14,791.08
| Professional | | $9,120.11 | $12,589.25 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $11,748.98
| Professional | | $3,235.94 | $4,073.80 | $11,748.98 |