- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,136.61 / $6,136.61 / $9,588.45
| Facility | | $6,136.61 | $6,136.61 | $9,588.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,658.08 / $8,464.02 / $9,588.45
| Professional | | $5,658.08 | $8,464.02 | $9,588.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,485.64 / $8,485.64 / $8,485.64
| Facility | | $8,485.64 | $8,485.64 | $8,485.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,485.64 / $8,485.64 / $8,485.64
| Professional | | $8,485.64 | $8,485.64 | $8,485.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,503.37
| Facility | | $7,503.37 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,477.46 / $7,503.37
| Professional | | $5,477.46 | $5,477.46 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,133.24 / $5,462.98 / $7,445.48
| Professional | | $3,133.24 | $5,462.98 | $7,445.48 |