- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,456.54 / $6,918.31
| Facility | | $4,897.79 | $6,456.54 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Professional | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $11,220.18 / $11,220.18
| Facility | | $1,659.59 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $11,220.18 / $11,220.18
| Professional | | $1,659.59 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,918.31 / $9,549.93
| Facility | | $4,897.79 | $6,918.31 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,762.47 / $16,218.10
| Professional | | $7,079.46 | $7,762.47 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $11,481.54 / $28,840.32
| Facility | | $6,918.31 | $11,481.54 | $28,840.32 |