- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,049.36 / $3,049.36 / $7,829.43
| Facility | | $3,049.36 | $3,049.36 | $7,829.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,049.36 / $4,235.41 / $7,829.43
| Professional | | $3,049.36 | $4,235.41 | $7,829.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,412.03 / $9,412.03 / $9,412.03
| Facility | | $9,412.03 | $9,412.03 | $9,412.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,445.78 / $5,539.38 / $12,089.57
| Professional | | $5,445.78 | $5,539.38 | $12,089.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $6,928.92
| Facility | | $6,553.03 | $6,553.03 | $6,928.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,412.20 / $6,749.62
| Professional | | $4,783.71 | $6,412.20 | $6,749.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,233.93 / $7,529.62 / $12,235.64
| Professional | | $5,233.93 | $7,529.62 | $12,235.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,182.35 / $5,031.08 / $6,950.87
| Professional | | $4,182.35 | $5,031.08 | $6,950.87 |