- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,213.03 / $13,037.26 / $13,037.26
| Facility | | $5,213.03 | $13,037.26 | $13,037.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Professional | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,774.88 / $11,774.88 / $11,774.88
| Facility | | $11,774.88 | $11,774.88 | $11,774.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,924.00 / $10,924.00 / $10,924.00
| Professional | | $10,924.00 | $10,924.00 | $10,924.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $6,597.54
| Facility | | $5,075.03 | $5,075.03 | $6,597.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,180.53 / $3,531.82 / $4,036.67
| Professional | | $3,180.53 | $3,531.82 | $4,036.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,745.97 / $22,936.04 / $22,936.04
| Facility | | $6,745.97 | $22,936.04 | $22,936.04 |