- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,947.35 / $5,921.03 / $8,171.01
| Facility | | $3,947.35 | $5,921.03 | $8,171.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,861.64 / $3,971.43 / $13,248.00
| Professional | | $3,861.64 | $3,971.43 | $13,248.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,320.00 / $16,960.00 / $16,960.00
| Facility | | $16,320.00 | $16,960.00 | $16,960.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,320.00 / $16,960.00 / $16,960.00
| Professional | | $16,320.00 | $16,960.00 | $16,960.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,320.00 / $26,288.00 / $26,288.00
| Facility | | $16,320.00 | $26,288.00 | $26,288.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,680.00 / $19,200.00 / $19,200.00
| Professional | | $7,680.00 | $19,200.00 | $19,200.00 |