- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $15,488.17
| Facility | | $10,964.78 | $10,964.78 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,623.41 / $5,623.41
| Professional | | $3,548.13 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $8,317.64
| Professional | | $6,606.93 | $6,606.93 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $3,467.37
| Professional | | $1,819.70 | $3,019.95 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $12,302.69 / $12,302.69
| Professional | | $6,456.54 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,388.44 / $4,466.84
| Professional | | $1,819.70 | $3,388.44 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,782.79 / $17,782.79 / $17,782.79
| Professional | | $17,782.79 | $17,782.79 | $17,782.79 |