- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,707.79 / $6,707.79 / $10,480.92
| Facility | | $6,707.79 | $6,707.79 | $10,480.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,296.61 / $10,224.32 / $10,515.37
| Professional | | $6,296.61 | $10,224.32 | $10,515.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,275.44 / $9,275.44 / $9,275.44
| Facility | | $9,275.44 | $9,275.44 | $9,275.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,275.44 / $9,275.44 / $9,275.44
| Professional | | $9,275.44 | $9,275.44 | $9,275.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.18 / $8,121.18 / $8,121.18
| Facility | | $8,121.18 | $8,121.18 | $8,121.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $11,392.76
| Professional | | $5,928.46 | $5,928.46 | $11,392.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,980.97 / $5,971.46 / $9,445.27
| Professional | | $3,980.97 | $5,971.46 | $9,445.27 |