- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,901.41 / $5,901.41 / $9,220.95
| Facility | | $5,901.41 | $5,901.41 | $9,220.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,901.41 / $9,220.95 / $10,534.90
| Professional | | $5,901.41 | $9,220.95 | $10,534.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,160.40 / $8,160.40 / $8,160.40
| Facility | | $8,160.40 | $8,160.40 | $8,160.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,160.40 / $8,160.40 / $8,160.40
| Professional | | $8,160.40 | $8,160.40 | $8,160.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,136.27 / $8,136.27 / $8,136.27
| Facility | | $8,136.27 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $5,939.48 / $8,136.27
| Professional | | $5,939.48 | $5,939.48 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,502.40 / $5,460.53 / $8,318.20
| Professional | | $3,502.40 | $5,460.53 | $8,318.20 |