- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $8,709.64
| Facility | | $5,495.41 | $5,495.41 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $8,511.38
| Professional | | $4,265.80 | $5,370.32 | $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
- $7,585.78 / $7,585.78 / $7,585.78
| Professional | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $7,943.28
| Professional | | $6,760.83 | $6,760.83 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $12,302.69
| Facility | | $5,888.44 | $7,943.28 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,677.35 / $6,918.31
| Professional | | $2,951.21 | $4,677.35 | $6,918.31 |