- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,456.54 / $9,120.11
| Professional | | $4,677.35 | $6,456.54 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $7,079.46
| Professional | | $2,754.23 | $2,754.23 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $5,011.87 / $14,791.08
| Professional | | $724.44 | $5,011.87 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,165.95 / $9,120.11
| Facility | | $3,890.45 | $6,165.95 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $5,623.41
| Professional | | $1,949.84 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,047.13 / $5,495.41
| Facility | | $389.05 | $1,047.13 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $5,623.41
| Professional | | $1,949.84 | $3,388.44 | $5,623.41 |