- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,709.64
| Facility | | $6,309.57 | $6,309.57 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,265.80 / $6,309.57
| Professional | | $3,311.31 | $4,265.80 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $7,762.47
| Facility | | $5,754.40 | $5,754.40 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,760.83
| Professional | | $5,128.61 | $5,128.61 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,456.54 / $9,332.54
| Facility | | $3,235.94 | $6,456.54 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,011.87
| Facility | | $4,466.84 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $5,011.87
| Professional | | $2,089.30 | $3,019.95 | $5,011.87 |