- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $9,549.93
| Facility | | $6,918.31 | $6,918.31 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $6,918.31
| Professional | | $3,311.31 | $4,677.35 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $7,413.10
| Professional | | $5,623.41 | $5,623.41 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $10,232.93
| Facility | | $3,548.13 | $4,365.16 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,495.41
| Facility | | $4,897.79 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $5,495.41
| Professional | | $2,290.87 | $3,311.31 | $5,495.41 |