- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,363.35 / $6,363.35 / $6,498.42
| Facility | | $6,363.35 | $6,363.35 | $6,498.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,397.34 / $6,131.64 / $7,603.93
| Professional | | $4,397.34 | $6,131.64 | $7,603.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,787.26 / $2,787.26 / $2,787.26
| Facility | | $2,787.26 | $2,787.26 | $2,787.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,129.43 / $5,129.43 / $6,770.84
| Professional | | $5,129.43 | $5,129.43 | $6,770.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,818.66 / $3,818.66 / $3,818.66
| Facility | | $3,818.66 | $3,818.66 | $3,818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.60 / $3,818.66 / $4,701.51
| Professional | | $775.60 | $3,818.66 | $4,701.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,317.39 / $3,367.64 / $5,186.39
| Professional | | $2,317.39 | $3,367.64 | $5,186.39 |