- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,308.81 / $3,308.81 / $8,495.60
| Facility | | $3,308.81 | $3,308.81 | $8,495.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,308.81 / $4,617.97 / $8,495.60
| Professional | | $3,308.81 | $4,617.97 | $8,495.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,212.86 / $10,212.86 / $10,212.86
| Facility | | $10,212.86 | $10,212.86 | $10,212.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,554.10 / $5,623.53 / $12,330.05
| Professional | | $5,554.10 | $5,623.53 | $12,330.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $7,518.47
| Facility | | $7,261.93 | $7,261.93 | $7,518.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,589.10 / $5,301.21 / $7,261.93
| Professional | | $4,589.10 | $5,301.21 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,679.25 / $8,170.29 / $13,276.72
| Professional | | $5,679.25 | $8,170.29 | $13,276.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,612.32 / $4,694.37 / $7,542.28
| Professional | | $3,612.32 | $4,694.37 | $7,542.28 |