- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $12,302.69
| Facility | | $7,585.78 | $7,585.78 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $7,413.10
| Professional | | $2,691.53 | $2,691.53 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $3,630.78 / $4,897.79
| Professional | | $851.14 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,378.01 / $17,378.01 / $17,378.01
| Facility | | $17,378.01 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $9,120.11
| Professional | | $7,585.78 | $7,585.78 | $9,120.11 |
- 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
- $2,691.53 / $2,691.53 / $7,413.10
| Professional | | $2,691.53 | $2,691.53 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,585.78 / $11,481.54
| Professional | | $4,570.88 | $7,585.78 | $11,481.54 |