- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,394.75 / $5,394.75 / $44,021.20
| Facility | | $5,394.75 | $5,394.75 | $44,021.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,394.75 / $5,394.75 / $5,610.54
| Professional | | $5,394.75 | $5,394.75 | $5,610.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,473.70 / $6,473.70
| Professional | | $5,754.40 | $6,473.70 | $6,473.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,688.63 / $12,156.17 / $26,148.66
| Facility | | $11,688.63 | $12,156.17 | $26,148.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,201.09 / $9,488.81 / $56,045.23
| Professional | | $4,201.09 | $9,488.81 | $56,045.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,271.95 / $14,621.21 / $14,621.21
| Professional | | $8,271.95 | $14,621.21 | $14,621.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,021.06 / $3,021.06 / $3,021.06
| Facility | | $3,021.06 | $3,021.06 | $3,021.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $4,315.80 / $11,436.87
| Professional | | $3,021.06 | $4,315.80 | $11,436.87 |