- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.64 / $4,536.64 / $4,536.64
| Facility | | $4,536.64 | $4,536.64 | $4,536.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,449.25 / $4,536.64 / $4,879.39
| Professional | | $4,449.25 | $4,536.64 | $4,879.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,013.64 / $11,629.66 / $16,190.56
| Facility | | $6,013.64 | $11,629.66 | $16,190.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,607.06 / $6,476.23 / $9,612.11
| Professional | | $5,607.06 | $6,476.23 | $9,612.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,541.83 / $6,541.83 / $10,448.18
| Facility | | $6,541.83 | $6,541.83 | $10,448.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $6,541.83 / $43,791.48
| Professional | | $4,775.54 | $6,541.83 | $43,791.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,078.09 / $9,078.09 / $9,078.09
| Facility | | $9,078.09 | $9,078.09 | $9,078.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,519.28 / $5,582.26 / $8,036.29
| Professional | | $4,519.28 | $5,582.26 | $8,036.29 |