- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $9,549.93
| Facility | | $6,165.95 | $6,165.95 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,754.40 / $9,120.11
| Professional | | $4,786.30 | $5,754.40 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Professional | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $7,585.78
| Professional | | $5,495.41 | $5,495.41 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,709.64 / $12,882.50
| Facility | | $4,786.30 | $8,709.64 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,248.07 / $7,244.36
| Professional | | $3,162.28 | $5,248.07 | $7,244.36 |