- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $7,413.10
| Facility | | $4,786.30 | $4,786.30 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $7,943.28
| Professional | | $3,890.45 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $20,892.96
| Facility | | $19,054.61 | $19,054.61 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,197.01 / $18,197.01 / $18,197.01
| Professional | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $7,585.78
| Professional | | $6,456.54 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $8,709.64 / $13,803.84
| Facility | | $7,413.10 | $8,709.64 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,495.41 / $14,125.38
| Professional | | $3,715.35 | $5,495.41 | $14,125.38 |