- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,897.79 / $8,511.38
| Professional | | $4,168.69 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $13,182.57
| Facility | | $6,456.54 | $6,456.54 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $11,748.98
| Professional | | $6,918.31 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $14,791.08 / $14,791.08
| Facility | | $7,943.28 | $14,791.08 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $44,668.36
| Professional | | $6,760.83 | $6,760.83 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,888.44 / $10,232.93
| Facility | | $5,128.61 | $5,888.44 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,309.57 / $8,317.64
| Professional | | $4,677.35 | $6,309.57 | $8,317.64 |