- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $12,022.64
| Facility | | $4,677.35 | $4,677.35 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $6,309.57
| Professional | | $4,677.35 | $5,128.61 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $13,489.63 / $15,135.61
| Professional | | $9,772.37 | $13,489.63 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $9,772.37
| Professional | | $7,762.47 | $7,762.47 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,128.61 / $12,022.64
| Facility | | $4,073.80 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,943.28 / $13,489.63
| Professional | | $2,818.38 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,918.31 / $11,481.54
| Professional | | $2,818.38 | $6,918.31 | $11,481.54 |