- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,606.93 / $7,244.36
| Professional | | $3,715.35 | $6,606.93 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $8,128.31
| Professional | | $5,128.61 | $5,128.61 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $20,417.38
| Facility | | $1,548.82 | $1,548.82 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $7,943.28 / $12,882.50
| Professional | | $812.83 | $7,943.28 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,174.90 / $6,309.57
| Facility | | $478.63 | $1,174.90 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,801.89 / $6,309.57
| Professional | | $2,398.83 | $3,801.89 | $6,309.57 |