- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,841.02 / $4,841.02 / $4,841.02
| Facility | | $4,841.02 | $4,841.02 | $4,841.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,778.45 / $4,841.02 / $5,206.75
| Professional | | $4,778.45 | $4,841.02 | $5,206.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,417.11 / $13,327.83 / $17,276.82
| Facility | | $6,417.11 | $13,327.83 | $17,276.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,417.11 / $7,089.36 / $12,153.18
| Professional | | $6,417.11 | $7,089.36 | $12,153.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,687.89 / $5,687.89 / $11,868.34
| Facility | | $5,687.89 | $5,687.89 | $11,868.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.71 / $5,687.89 / $45,898.50
| Professional | | $4,834.71 | $5,687.89 | $45,898.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116,212.54 / $116,212.54 / $116,212.54
| Facility | | $116,212.54 | $116,212.54 | $116,212.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,925.26 / $6,842.23 / $8,208.77
| Professional | | $4,925.26 | $6,842.23 | $8,208.77 |