- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,897.79 / $6,025.60
| Facility | | $4,168.69 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,265.80 / $6,309.57
| Professional | | $2,754.23 | $4,265.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,677.35 / $5,623.41
| Professional | | $4,466.84 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,025.60 / $7,585.78
| Professional | | $5,495.41 | $6,025.60 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,011.87 / $7,585.78
| Professional | | $2,511.89 | $5,011.87 | $7,585.78 |