- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,225.47 / $6,225.47 / $6,591.64
| Facility | | $6,225.47 | $6,225.47 | $6,591.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,928.64 / $5,927.74 / $7,800.58
| Professional | | $4,928.64 | $5,927.74 | $7,800.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,969.70 / $15,304.29 / $15,304.29
| Facility | | $9,969.70 | $15,304.29 | $15,304.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,135.29 / $7,430.74 / $7,750.19
| Professional | | $6,135.29 | $7,430.74 | $7,750.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.43 / $4,933.43 / $6,993.18
| Facility | | $4,933.43 | $4,933.43 | $6,993.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.42 / $4,933.43 / $8,742.04
| Professional | | $4,193.42 | $4,933.43 | $8,742.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $517.10 / $4,036.99 / $7,477.28
| Facility | | $517.10 | $4,036.99 | $7,477.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,871.72 / $5,088.18 / $8,223.86
| Professional | | $3,871.72 | $5,088.18 | $8,223.86 |