- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,134.05 / $3,134.05 / $8,046.89
| Facility | | $3,134.05 | $3,134.05 | $8,046.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,134.05 / $4,689.64 / $8,046.89
| Professional | | $3,134.05 | $4,689.64 | $8,046.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,673.45 / $9,673.45 / $9,673.45
| Facility | | $9,673.45 | $9,673.45 | $9,673.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,658.08 / $6,543.68 / $12,560.87
| Professional | | $5,658.08 | $6,543.68 | $12,560.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,121.37 / $7,503.37 / $7,503.37
| Facility | | $7,121.37 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $6,806.53 / $7,998.97
| Professional | | $5,477.46 | $6,806.53 | $7,998.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,379.30 / $7,738.76 / $12,575.49
| Professional | | $5,379.30 | $7,738.76 | $12,575.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,345.39 / $4,825.97 / $7,242.34
| Professional | | $4,345.39 | $4,825.97 | $7,242.34 |