- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,415.40 / $3,415.40 / $8,769.28
| Facility | | $3,415.40 | $3,415.40 | $8,769.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,415.40 / $4,743.83 / $8,769.28
| Professional | | $3,415.40 | $4,743.83 | $8,769.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,541.85 / $10,541.85 / $10,541.85
| Facility | | $10,541.85 | $10,541.85 | $10,541.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,324.72 / $6,433.43 / $14,040.80
| Professional | | $6,324.72 | $6,433.43 | $14,040.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,760.68 / $8,136.27 / $8,136.27
| Facility | | $7,760.68 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $7,961.42 / $8,380.36
| Professional | | $5,939.48 | $7,961.42 | $8,380.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,862.21 / $8,433.48 / $13,704.41
| Professional | | $5,862.21 | $8,433.48 | $13,704.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,113.52 / $5,253.60 / $8,039.42
| Professional | | $4,113.52 | $5,253.60 | $8,039.42 |