- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $15,135.61
| Facility | | $5,888.44 | $5,888.44 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $7,585.78
| Professional | | $5,888.44 | $5,888.44 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,302.69 / $16,218.10 / $19,054.61
| Professional | | $12,302.69 | $16,218.10 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $12,022.64
| Professional | | $9,772.37 | $9,772.37 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,456.54 / $15,135.61
| Facility | | $5,128.61 | $6,456.54 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,365.16 / $10,232.93
| Professional | | $1,548.82 | $4,365.16 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,365.16 / $10,232.93
| Professional | | $1,548.82 | $4,365.16 | $10,232.93 |