- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,794.02 / $5,794.02 / $9,053.15
| Facility | | $5,794.02 | $5,794.02 | $9,053.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,438.85 / $8,423.96 / $9,053.15
| Professional | | $5,438.85 | $8,423.96 | $9,053.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,011.89 / $8,011.89 / $8,011.89
| Facility | | $8,011.89 | $8,011.89 | $8,011.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,011.89 / $8,011.89 / $8,011.89
| Professional | | $8,011.89 | $8,011.89 | $8,011.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $6,652.12
| Facility | | $6,652.12 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $4,856.05 / $6,652.12
| Professional | | $4,856.05 | $4,856.05 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,067.77 / $5,157.99 / $7,091.00
| Professional | | $3,067.77 | $5,157.99 | $7,091.00 |