- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,495.41 / $7,413.10
| Facility | | $5,248.07 | $5,495.41 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,466.84 / $5,248.07
| Professional | | $4,265.80 | $4,466.84 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Professional | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $1,737.80
| Facility | | $1,318.26 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,754.40
| Professional | | $5,248.07 | $5,248.07 | $5,754.40 |