- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,064.26 / $10,154.87 / $10,890.73
| Facility | | $7,064.26 | $10,154.87 | $10,890.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,064.26 / $10,154.87 / $10,890.73
| Professional | | $7,064.26 | $10,154.87 | $10,890.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,611.06 / $7,848.27 / $12,509.62
| Professional | | $6,611.06 | $7,848.27 | $12,509.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,777.03 / $10,777.03 / $10,777.03
| Professional | | $10,777.03 | $10,777.03 | $10,777.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,546.22 / $10,890.73 / $69,378.71
| Facility | | $1,546.22 | $10,890.73 | $69,378.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,938.57 / $7,049.67 / $15,299.20
| Professional | | $4,938.57 | $7,049.67 | $15,299.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,938.57 / $6,761.18 / $12,941.48
| Professional | | $4,938.57 | $6,761.18 | $12,941.48 |