- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,490.61 / $18,290.80 / $23,980.50
| Facility | | $3,490.61 | $18,290.80 | $23,980.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.61 / $3,490.61 / $3,490.61
| Professional | | $3,490.61 | $3,490.61 | $3,490.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,315.10 / $3,409.58 / $10,686.48
| Facility | | $3,315.10 | $3,409.58 | $10,686.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,654.14 / $4,654.14 / $4,654.14
| Professional | | $4,654.14 | $4,654.14 | $4,654.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,994.80 / $4,460.22 / $4,460.22
| Facility | | $3,994.80 | $4,460.22 | $4,460.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,016.10 / $4,462.33 / $5,796.37
| Professional | | $4,016.10 | $4,462.33 | $5,796.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $1,628.95 / $2,327.07
| Professional | | $1,628.95 | $1,628.95 | $2,327.07 |