- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,495.41 / $9,772.37
| Facility | | $3,388.44 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $9,772.37
| Professional | | $9,772.37 | $9,772.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $18,197.01 / $28,840.32
| Facility | | $8,511.38 | $18,197.01 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Professional | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,495.41 / $11,481.54
| Facility | | $3,388.44 | $5,495.41 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,709.64 / $9,772.37
| Professional | | $4,466.84 | $8,709.64 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $20,892.96 / $29,512.09
| Facility | | $10,964.78 | $20,892.96 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $21,877.62 / $24,547.09
| Professional | | $15,135.61 | $21,877.62 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $12,302.69 / $12,302.69
| Facility | | $5,495.41 | $12,302.69 | $12,302.69 |