- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,193.00 / $13,163.20 / $14,601.80
| Facility | | $7,193.00 | $13,163.20 | $14,601.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,682.47 / $13,163.19 / $14,601.79
| Professional | | $5,682.47 | $13,163.19 | $14,601.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,912.30 / $7,912.30 / $7,912.30
| Facility | | $7,912.30 | $7,912.30 | $7,912.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,912.30 / $7,912.30 / $7,912.30
| Professional | | $7,912.30 | $7,912.30 | $7,912.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,675.45 / $4,675.45 / $4,909.22
| Facility | | $4,675.45 | $4,675.45 | $4,909.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,115.02 / $5,748.84 / $10,845.23
| Professional | | $3,115.02 | $5,748.84 | $10,845.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $4,315.80 / $12,228.10
| Professional | | $3,021.06 | $4,315.80 | $12,228.10 |