- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $9,549.93
| Facility | | $6,025.60 | $6,025.60 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,623.41 / $9,120.11
| Professional | | $4,677.35 | $5,623.41 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Professional | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $7,244.36
| Professional | | $5,248.07 | $5,248.07 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,709.64 / $12,589.25
| Facility | | $5,128.61 | $8,709.64 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,128.61 / $7,244.36
| Professional | | $3,090.30 | $5,128.61 | $7,244.36 |