- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $13,489.63
| Facility | | $11,220.18 | $11,220.18 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $6,309.57 / $13,489.63
| Professional | | $3,715.35 | $6,309.57 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $7,585.78
| Professional | | $6,456.54 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $26,915.35
| Professional | | $15,135.61 | $15,135.61 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,762.47 / $13,803.84
| Facility | | $5,754.40 | $7,762.47 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,715.19 / $15,135.61
| Professional | | $3,890.45 | $10,715.19 | $15,135.61 |