- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,702.14 / $24,639.20 / $32,303.70
| Facility | | $4,702.14 | $24,639.20 | $32,303.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,702.14 / $4,702.14 / $4,702.14
| Professional | | $4,702.14 | $4,702.14 | $4,702.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,465.72 / $4,593.00 / $14,395.60
| Facility | | $4,465.72 | $4,593.00 | $14,395.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,269.52 / $6,269.52 / $6,269.52
| Professional | | $6,269.52 | $6,269.52 | $6,269.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,224.60 / $6,008.29 / $6,269.52
| Facility | | $5,224.60 | $6,008.29 | $6,269.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,224.60 / $6,011.19 / $7,808.26
| Professional | | $5,224.60 | $6,011.19 | $7,808.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.33 / $2,194.33 / $3,134.76
| Professional | | $2,194.33 | $2,194.33 | $3,134.76 |