- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,831.31 / $4,831.31 / $4,831.31
| Facility | | $4,831.31 | $4,831.31 | $4,831.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,831.31 / $4,831.31 / $4,831.31
| Professional | | $4,831.31 | $4,831.31 | $4,831.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,431.56 / $18,101.73 / $20,621.32
| Facility | | $16,431.56 | $18,101.73 | $20,621.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,987.70 / $16,456.12 / $18,011.68
| Professional | | $13,987.70 | $16,456.12 | $18,011.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,750.13 / $7,827.63 / $9,842.66
| Professional | | $7,750.13 | $7,827.63 | $9,842.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,398.77 / $7,398.77 / $7,398.77
| Facility | | $7,398.77 | $7,398.77 | $7,398.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.13 / $2,209.13 / $3,507.14
| Professional | | $2,209.13 | $2,209.13 | $3,507.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.13 / $2,209.13 / $3,507.14
| Professional | | $2,209.13 | $2,209.13 | $3,507.14 |