- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $18,620.87 / $18,620.87
| Facility | | $8,511.38 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,466.84 / $6,918.31
| Professional | | $3,801.89 | $4,466.84 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $11,748.98
| Professional | | $8,511.38 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,606.93 / $10,471.29
| Facility | | $3,630.78 | $6,606.93 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,025.60 / $6,025.60
| Professional | | $5,754.40 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,311.31
| Professional | | $2,290.87 | $2,290.87 | $3,311.31 |