- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,739.93 / $7,739.93 / $7,904.21
| Facility | | $7,739.93 | $7,739.93 | $7,904.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,348.61 / $7,458.11 / $9,248.93
| Professional | | $5,348.61 | $7,458.11 | $9,248.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,390.20 / $3,390.20 / $3,390.20
| Facility | | $3,390.20 | $3,390.20 | $3,390.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,427.41 / $6,684.62 / $8,235.69
| Professional | | $5,427.41 | $6,684.62 | $8,235.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $4,978.93 / $6,144.24
| Professional | | $4,232.09 | $4,978.93 | $6,144.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,977.53 / $4,155.43 / $6,752.67
| Professional | | $2,977.53 | $4,155.43 | $6,752.67 |