- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,383.98 / $6,383.98 / $6,383.98
| Facility | | $6,383.98 | $6,383.98 | $6,383.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,174.72 / $6,383.98 / $7,745.68
| Professional | | $6,174.72 | $6,383.98 | $7,745.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,162.16 / $8,517.04 / $11,931.60
| Facility | | $8,162.16 | $8,517.04 | $11,931.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,307.94 / $10,384.92 / $11,178.60
| Professional | | $8,307.94 | $10,384.92 | $11,178.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,539.60 / $6,539.60 / $26,741.88
| Facility | | $6,539.60 | $6,539.60 | $26,741.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,341.25 / $12,464.66 / $15,673.39
| Professional | | $12,341.25 | $12,464.66 | $15,673.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,916.65 / $18,916.65 / $21,056.60
| Facility | | $18,916.65 | $18,916.65 | $21,056.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,341.25 / $12,341.25 / $12,341.25
| Professional | | $12,341.25 | $12,341.25 | $12,341.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,007.68 / $7,097.54 / $10,646.31
| Facility | | $4,007.68 | $7,097.54 | $10,646.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.51 / $3,367.27 / $7,127.21
| Professional | | $2,006.51 | $3,367.27 | $7,127.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.51 / $3,360.90 / $7,127.21
| Professional | | $2,006.51 | $3,360.90 | $7,127.21 |