- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $6,025.60 / $6,025.60
| Facility | | $1,412.54 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,754.40 / $6,456.54
| Professional | | $5,011.87 | $5,754.40 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $7,585.78
| Facility | | $6,165.95 | $6,165.95 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $9,772.37 / $9,772.37
| Facility | | $34.67 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,128.31 / $30,902.95
| Professional | | $5,128.61 | $8,128.31 | $30,902.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,025.60 / $9,549.93
| Professional | | $4,466.84 | $6,025.60 | $9,549.93 |