- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $4,897.79
| Facility | | $4,073.80 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $19,054.61
| Professional | | $19,054.61 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $5,754.40
| Facility | | $4,073.80 | $4,897.79 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $26,915.35
| Professional | | $19,054.61 | $19,054.61 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Professional | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $18,197.01
| Facility | | $6,456.54 | $10,232.93 | $18,197.01 |