- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,135.84 / $8,135.84 / $8,135.84
| Facility | | $8,135.84 | $8,135.84 | $8,135.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,135.84 / $12,679.28 / $24,033.86
| Professional | | $8,135.84 | $12,679.28 | $24,033.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,275.38 / $13,275.38 / $13,275.38
| Facility | | $13,275.38 | $13,275.38 | $13,275.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.46 / $11,284.07 / $13,275.38
| Professional | | $1,527.46 | $11,284.07 | $13,275.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,135.84 / $13,436.25 / $22,627.77
| Facility | | $8,135.84 | $13,436.25 | $22,627.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.14 / $2,053.14 / $2,161.19
| Professional | | $2,053.14 | $2,053.14 | $2,161.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.36 / $1,063.31 / $7,787.92
| Professional | | $648.36 | $1,063.31 | $7,787.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,178.32 / $6,109.84 / $11,583.30
| Professional | | $5,178.32 | $6,109.84 | $11,583.30 |