- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,244.36 / $7,244.36
| Facility | | $3,890.45 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,890.45 / $4,466.84
| Professional | | $3,311.31 | $3,890.45 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,585.78 / $14,454.40
| Facility | | $3,981.07 | $7,585.78 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,908.68 / $22,908.68 / $22,908.68
| Professional | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,137.96 / $6,025.60
| Professional | | $1,995.26 | $2,137.96 | $6,025.60 |