- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,439.69 / $3,439.69 / $8,831.62
| Facility | | $3,439.69 | $3,439.69 | $8,831.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,439.69 / $4,777.56 / $8,831.62
| Professional | | $3,439.69 | $4,777.56 | $8,831.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,616.81 / $10,616.81 / $10,616.81
| Facility | | $10,616.81 | $10,616.81 | $10,616.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,430.09 / $6,486.08 / $14,155.74
| Professional | | $6,430.09 | $6,486.08 | $14,155.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,815.84 / $8,302.44 / $8,302.44
| Facility | | $7,815.84 | $8,302.44 | $8,302.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $8,124.02 / $8,551.51
| Professional | | $6,060.78 | $8,124.02 | $8,551.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,903.88 / $8,493.45 / $13,801.85
| Professional | | $5,903.88 | $8,493.45 | $13,801.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,147.18 / $5,296.61 / $8,105.23
| Professional | | $4,147.18 | $5,296.61 | $8,105.23 |