- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,594.27 / $3,594.27 / $9,228.53
| Facility | | $3,594.27 | $3,594.27 | $9,228.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,594.27 / $4,992.27 / $9,228.53
| Professional | | $3,594.27 | $4,992.27 | $9,228.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,093.94 / $11,093.94 / $11,093.94
| Facility | | $11,093.94 | $11,093.94 | $11,093.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,763.44 / $6,777.58 / $14,791.91
| Professional | | $6,763.44 | $6,777.58 | $14,791.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,167.10 / $8,732.85 / $8,732.85
| Facility | | $8,167.10 | $8,732.85 | $8,732.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,374.98 / $8,545.18 / $8,994.84
| Professional | | $6,374.98 | $8,545.18 | $8,994.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,169.21 / $8,875.15 / $14,422.12
| Professional | | $6,169.21 | $8,875.15 | $14,422.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,544.86 / $5,544.86 / $5,544.86
| Facility | | $5,544.86 | $5,544.86 | $5,544.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,209.75 / $7,940.15 / $10,427.41
| Professional | | $5,209.75 | $7,940.15 | $10,427.41 |