- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,686.65 / $8,416.25 / $18,197.30
| Facility | | $5,686.65 | $8,416.25 | $18,197.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $18,197.30
| Professional | | $2,666.54 | $2,666.54 | $18,197.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,928.43 / $4,928.43 / $20,255.84
| Facility | | $4,928.43 | $4,928.43 | $20,255.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,235.41 / $9,235.41 / $11,065.06
| Professional | | $9,235.41 | $9,235.41 | $11,065.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,610.83 / $7,392.65 / $12,738.10
| Facility | | $5,610.83 | $7,392.65 | $12,738.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $3,184.52 / $11,373.30
| Professional | | $3,184.52 | $3,184.52 | $11,373.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $3,184.52 / $4,852.60
| Professional | | $3,184.52 | $3,184.52 | $4,852.60 |