- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,251.77 / $3,251.77 / $8,349.15
| Facility | | $3,251.77 | $3,251.77 | $8,349.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,251.77 / $4,516.56 / $8,349.15
| Professional | | $3,251.77 | $4,516.56 | $8,349.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,036.81 / $10,036.81 / $10,036.81
| Facility | | $10,036.81 | $10,036.81 | $10,036.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,539.84 / $5,635.06 / $12,298.39
| Professional | | $5,539.84 | $5,635.06 | $12,298.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $7,388.85
| Facility | | $6,652.12 | $6,652.12 | $7,388.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $6,509.17 / $6,851.68
| Professional | | $4,856.05 | $6,509.17 | $6,851.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,254.60 / $4,601.64 / $7,041.76
| Professional | | $4,254.60 | $4,601.64 | $7,041.76 |