- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,234.27 / $6,234.27 / $6,234.27
| Facility | | $6,234.27 | $6,234.27 | $6,234.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,234.27 / $6,234.27 / $7,350.86
| Professional | | $6,234.27 | $6,234.27 | $7,350.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,592.12 / $9,451.34 / $9,546.79
| Professional | | $8,592.12 | $9,451.34 | $9,546.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,957.05 / $10,753.52 / $10,753.52
| Facility | | $7,957.05 | $10,753.52 | $10,753.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,957.05 / $10,753.52 / $16,582.16
| Professional | | $7,957.05 | $10,753.52 | $16,582.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,083.75 / $10,700.61 / $43,045.38
| Facility | | $5,083.75 | $10,700.61 | $43,045.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,721.95 / $5,955.87 / $8,128.51
| Professional | | $3,721.95 | $5,955.87 | $8,128.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,722.06 / $10,753.52 / $13,602.03
| Facility | | $10,722.06 | $10,753.52 | $13,602.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,941.36 / $12,708.71 / $22,154.03
| Professional | | $8,941.36 | $12,708.71 | $22,154.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,147.53 / $10,147.53 / $10,147.53
| Facility | | $10,147.53 | $10,147.53 | $10,147.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,721.95 / $5,325.77 / $6,883.36
| Professional | | $3,721.95 | $5,325.77 | $6,883.36 |