- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $6,606.93
| Facility | | $4,466.84 | $5,370.32 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,265.80 / $6,918.31
| Professional | | $2,951.21 | $4,265.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $6,918.31
| Professional | | $5,495.41 | $5,495.41 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,606.93 / $8,128.31
| Professional | | $6,025.60 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,495.41 / $8,128.31
| Professional | | $2,754.23 | $5,495.41 | $8,128.31 |