- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $9,332.54 / $12,882.50
| Professional | | $6,456.54 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Professional | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,715.19 / $10,715.19
| Professional | | $3,890.45 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $10,232.93 / $25,118.86
| Facility | | $1,819.70 | $10,232.93 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,456.54 / $67,608.30
| Professional | | $4,365.16 | $6,456.54 | $67,608.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $4,466.84 / $10,232.93
| Facility | | $602.56 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,456.54 / $9,332.54
| Professional | | $4,365.16 | $6,456.54 | $9,332.54 |