- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,717.53 / $4,717.53 / $12,130.80
| Facility | | $4,717.53 | $4,717.53 | $12,130.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,717.53 / $4,717.53 / $6,334.97
| Professional | | $4,717.53 | $4,717.53 | $6,334.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,144.37 / $13,579.75 / $15,163.49
| Professional | | $10,144.37 | $13,579.75 | $15,163.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,744.16 / $7,744.16 / $11,368.79
| Professional | | $7,744.16 | $7,744.16 | $11,368.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,043.60 / $5,121.89 / $12,130.79
| Facility | | $4,043.60 | $5,121.89 | $12,130.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,437.06 / $8,087.20 / $13,478.66
| Professional | | $3,437.06 | $8,087.20 | $13,478.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.52 / $6,874.12 / $11,456.86
| Professional | | $2,830.52 | $6,874.12 | $11,456.86 |