- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,517.04 / $5,119.31 / $6,570.24
| Facility | | $4,517.04 | $5,119.31 | $6,570.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.86 / $2,901.86 / $2,901.86
| Professional | | $2,901.86 | $2,901.86 | $2,901.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,570.24 / $6,570.24 / $6,570.24
| Professional | | $6,570.24 | $6,570.24 | $6,570.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.20 / $5,475.20 / $5,733.19
| Professional | | $5,475.20 | $5,475.20 | $5,733.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,022.72 / $6,570.24 / $7,665.28
| Professional | | $6,022.72 | $6,570.24 | $7,665.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,475.20 / $6,570.24 / $8,212.79
| Professional | | $5,475.20 | $6,570.24 | $8,212.79 |