- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,899.21 / $2,899.21 / $7,443.91
| Facility | | $2,899.21 | $2,899.21 | $7,443.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,899.21 / $4,026.86 / $7,443.91
| Professional | | $2,899.21 | $4,026.86 | $7,443.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,948.58 / $8,948.58 / $8,948.58
| Facility | | $8,948.58 | $8,948.58 | $8,948.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,810.89 / $4,893.57 / $10,680.11
| Professional | | $4,810.89 | $4,893.57 | $10,680.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $6,587.75
| Facility | | $6,541.83 | $6,541.83 | $6,587.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,401.26 / $6,738.08
| Professional | | $4,775.54 | $6,401.26 | $6,738.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,976.21 / $7,158.86 / $11,633.15
| Professional | | $4,976.21 | $7,158.86 | $11,633.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.94 / $4,783.35 / $6,157.94
| Professional | | $3,128.94 | $4,783.35 | $6,157.94 |