- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $11,481.54
| Facility | | $5,011.87 | $5,011.87 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $5,011.87
| Professional | | $2,754.23 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,762.47 / $13,489.63
| Facility | | $5,495.41 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,011.87 / $6,918.31
| Professional | | $2,570.40 | $5,011.87 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $8,128.31 / $28,840.32
| Facility | | $3,235.94 | $8,128.31 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,332.54 / $10,964.78
| Professional | | $6,760.83 | $9,332.54 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $8,709.64
| Professional | | $2,398.83 | $3,019.95 | $8,709.64 |