- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $10,964.78
| Facility | | $6,760.83 | $6,760.83 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,677.35 / $6,606.93
| Professional | | $3,548.13 | $4,677.35 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $3,235.94 / $4,365.16
| Professional | | $426.58 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Facility | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,128.31
| Professional | | $6,760.83 | $6,760.83 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $6,760.83
| Facility | | $6,760.83 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,248.07 / $6,606.93
| Professional | | $3,630.78 | $5,248.07 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $6,760.83 / $9,772.37
| Professional | | $4,073.80 | $6,760.83 | $9,772.37 |