- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,042.84 / $6,042.84 / $9,441.94
| Facility | | $6,042.84 | $6,042.84 | $9,441.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,349.22 / $7,567.76 / $9,441.94
| Professional | | $5,349.22 | $7,567.76 | $9,441.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,355.96 / $8,355.96 / $8,355.96
| Facility | | $8,355.96 | $8,355.96 | $8,355.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,355.96 / $8,355.96 / $8,355.96
| Professional | | $8,355.96 | $8,355.96 | $8,355.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $7,261.93
| Facility | | $7,261.93 | $7,261.93 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $9,204.18
| Professional | | $5,301.21 | $5,301.21 | $9,204.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,075.66 / $5,379.50 / $7,331.70
| Professional | | $3,075.66 | $5,379.50 | $7,331.70 |