- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $15,135.61
| Facility | | $7,079.46 | $7,079.46 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,943.28 / $9,332.54
| Professional | | $6,025.60 | $7,943.28 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $7,585.78
| Facility | | $5,495.41 | $6,918.31 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $9,549.93
| Facility | | $5,888.44 | $7,943.28 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,943.28 / $7,943.28
| Professional | | $6,025.60 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $77.62
| Professional | | $30.20 | $30.20 | $77.62 |