- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $13,803.84
| Facility | | $8,511.38 | $8,511.38 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,456.54 / $8,317.64
| Professional | | $4,466.84 | $6,456.54 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $5,495.41
| Professional | | $1,548.82 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,498.45 / $19,498.45 / $19,498.45
| Facility | | $19,498.45 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $10,232.93
| Professional | | $8,511.38 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,606.93 / $8,317.64
| Professional | | $4,677.35 | $6,606.93 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,511.38 / $12,302.69
| Professional | | $5,128.61 | $8,511.38 | $12,302.69 |