- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,690.16 / $2,690.16 / $6,907.17
| Facility | | $2,690.16 | $2,690.16 | $6,907.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.16 / $3,319.37 / $6,907.17
| Professional | | $2,690.16 | $3,319.37 | $6,907.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,303.35 / $8,303.35 / $8,303.35
| Facility | | $8,303.35 | $8,303.35 | $8,303.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,740.27 / $3,804.46 / $8,303.35
| Professional | | $3,740.27 | $3,804.46 | $8,303.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $6,112.74
| Facility | | $4,366.38 | $4,366.38 | $6,112.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $5,487.71
| Professional | | $3,187.46 | $4,366.38 | $5,487.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,617.39 / $6,642.68 / $10,794.36
| Professional | | $4,617.39 | $6,642.68 | $10,794.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.62 / $3,106.84 / $5,178.07
| Professional | | $2,432.62 | $3,106.84 | $5,178.07 |