- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $7,943.28
| Facility | | $870.96 | $1,819.70 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $7,943.28 / $10,232.93
| Professional | | $2,570.40 | $7,943.28 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28,183.83 / $28,183.83 / $33,113.11
| Facility | | $28,183.83 | $28,183.83 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Professional | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,113.11 / $33,113.11 / $33,113.11
| Facility | | $33,113.11 | $33,113.11 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $42.66 / $50.12
| Professional | | $38.02 | $42.66 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $9,332.54 / $41,686.94
| Facility | | $1,348.96 | $9,332.54 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $12,302.69 / $25,118.86
| Professional | | $9,332.54 | $12,302.69 | $25,118.86 |