- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,734.65 / $5,734.65 / $5,734.65
| Facility | | $5,734.65 | $5,734.65 | $5,734.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,664.18 / $5,811.11 / $7,152.22
| Professional | | $4,664.18 | $5,811.11 | $7,152.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,741.51 / $6,889.81 / $8,672.74
| Professional | | $5,741.51 | $6,889.81 | $8,672.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,623.95 / $3,087.00 / $3,790.53
| Professional | | $2,623.95 | $3,087.00 | $3,790.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,572.63 / $6,161.32 / $6,161.32
| Facility | | $4,572.63 | $6,161.32 | $6,161.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.15 / $2,916.32 / $3,998.20
| Professional | | $1,954.15 | $2,916.32 | $3,998.20 |