- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $12,022.64 / $16,595.87
| Facility | | $3,890.45 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $12,882.50 / $16,595.87
| Professional | | $10,715.19 | $12,882.50 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $13,489.63
| Facility | | $3,235.94 | $3,311.31 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $3,890.45
| Professional | | $60.26 | $60.26 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,311.31 / $4,365.16
| Facility | | $3,235.94 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |