- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,769.52 / $5,769.52 / $14,813.64
| Facility | | $5,769.52 | $5,769.52 | $14,813.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,769.52 / $8,013.60 / $14,813.64
| Professional | | $5,769.52 | $8,013.60 | $14,813.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,808.00 / $17,808.00 / $17,808.00
| Facility | | $17,808.00 | $17,808.00 | $17,808.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,344.35 / $10,344.35 / $22,680.77
| Professional | | $10,344.35 | $10,344.35 | $22,680.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $13,109.84
| Facility | | $11,736.82 | $11,736.82 | $13,109.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $11,484.62 / $12,512.04
| Professional | | $8,567.87 | $11,484.62 | $12,512.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,902.83 / $14,246.41 / $23,150.41
| Professional | | $9,902.83 | $14,246.41 | $23,150.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,846.36 / $9,051.59 / $13,077.26
| Professional | | $7,846.36 | $9,051.59 | $13,077.26 |