- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $7,943.28 / $11,748.98
| Professional | | $5,623.41 | $7,943.28 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,454.40 / $16,982.44 / $17,378.01
| Professional | | $14,454.40 | $16,982.44 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,791.08 / $15,135.61 / $18,620.87
| Professional | | $14,791.08 | $15,135.61 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,511.38 / $14,125.38
| Facility | | $6,760.83 | $8,511.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,630.78 / $6,760.83
| Professional | | $3,388.44 | $3,630.78 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $4,786.30
| Facility | | $724.44 | $724.44 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,981.07 / $8,709.64
| Professional | | $2,041.74 | $3,981.07 | $8,709.64 |