- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,041.58 / $8,041.58 / $8,041.58
| Facility | | $8,041.58 | $8,041.58 | $8,041.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,663.06 / $10,977.39 / $32,008.70
| Professional | | $6,663.06 | $10,977.39 | $32,008.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,732.85 / $8,732.85 / $8,732.85
| Facility | | $8,732.85 | $8,732.85 | $8,732.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,374.98 / $8,732.85 / $8,732.85
| Professional | | $6,374.98 | $8,732.85 | $8,732.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,661.85 / $14,577.32 / $21,865.98
| Professional | | $11,661.85 | $14,577.32 | $21,865.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,573.07 / $3,573.07 / $10,954.94
| Facility | | $3,573.07 | $3,573.07 | $10,954.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,374.98 / $8,732.85 / $13,000.70
| Professional | | $6,374.98 | $8,732.85 | $13,000.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,018.89 / $5,534.64 / $8,469.50
| Professional | | $5,018.89 | $5,534.64 | $8,469.50 |