- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $10,471.29
| Facility | | $6,760.83 | $6,760.83 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,760.83 / $10,471.29
| Professional | | $5,128.61 | $6,760.83 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Professional | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,128.31
| Professional | | $5,888.44 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,549.93 / $16,218.10
| Facility | | $6,025.60 | $9,549.93 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $9,120.11
| Professional | | $3,981.07 | $5,888.44 | $9,120.11 |