- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,063.18 / $9,063.18 / $12,515.80
| Facility | | $9,063.18 | $9,063.18 | $12,515.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,315.80 / $6,977.21 / $9,063.18
| Professional | | $4,315.80 | $6,977.21 | $9,063.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,675.45 / $5,423.52 / $12,904.24
| Facility | | $4,675.45 | $5,423.52 | $12,904.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,033.34 / $6,552.73 / $11,183.44
| Professional | | $3,033.34 | $6,552.73 | $11,183.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,473.70 / $6,473.70 / $6,473.70
| Facility | | $6,473.70 | $6,473.70 | $6,473.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $4,315.80 / $7,193.00
| Professional | | $3,021.06 | $4,315.80 | $7,193.00 |