- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $12,882.50 / $15,848.93
| Facility | | $8,128.31 | $12,882.50 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $12,589.25 / $16,982.44
| Professional | | $8,128.31 | $12,589.25 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $39,810.72
| Facility | | $1,412.54 | $1,412.54 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $15,848.93 / $21,877.62
| Professional | | $8,128.31 | $15,848.93 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $13,182.57 / $13,182.57
| Facility | | $10,232.93 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $13,182.57 / $31,622.78
| Professional | | $1,621.81 | $13,182.57 | $31,622.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,187.76 / $9,549.93
| Facility | | $660.69 | $2,187.76 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,918.31 / $11,481.54
| Professional | | $4,677.35 | $6,918.31 | $11,481.54 |