- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,350.86 / $7,350.86 / $7,350.86
| Facility | | $7,350.86 | $7,350.86 | $7,350.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,883.76 / $5,117.68 / $8,188.29
| Professional | | $2,883.76 | $5,117.68 | $8,188.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,414.92 / $8,090.05 / $8,581.04
| Facility | | $7,414.92 | $8,090.05 | $8,581.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,030.02 / $8,030.02 / $8,030.02
| Professional | | $8,030.02 | $8,030.02 | $8,030.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,957.05 / $7,957.05 / $7,957.05
| Facility | | $7,957.05 | $7,957.05 | $7,957.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,763.49 / $7,957.05 / $14,704.69
| Professional | | $6,763.49 | $7,957.05 | $14,704.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,883.76 / $7,878.61 / $43,045.38
| Facility | | $2,883.76 | $7,878.61 | $43,045.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,977.94 / $5,225.60 / $12,489.36
| Professional | | $2,977.94 | $5,225.60 | $12,489.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,147.53 / $10,147.53 / $11,938.27
| Facility | | $10,147.53 | $10,147.53 | $11,938.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.40 / $4,877.10 / $6,883.36
| Professional | | $3,251.40 | $4,877.10 | $6,883.36 |