- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,753.64 / $5,046.17 / $7,167.02
| Facility | | $4,753.64 | $5,046.17 | $7,167.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,026.86 / $5,046.17 / $7,313.29
| Professional | | $4,026.86 | $5,046.17 | $7,313.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,655.55 / $13,078.36 / $18,383.41
| Facility | | $7,655.55 | $13,078.36 | $18,383.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,220.81 / $6,244.79 / $6,244.79
| Professional | | $5,220.81 | $6,244.79 | $6,244.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,541.83
| Facility | | $6,541.83 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $6,541.83
| Professional | | $4,775.54 | $6,541.83 | $6,541.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,078.09 / $10,680.11 / $10,680.11
| Facility | | $9,078.09 | $10,680.11 | $10,680.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.10 / $4,387.97 / $6,157.94
| Professional | | $2,664.10 | $4,387.97 | $6,157.94 |