- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,943.29 / $4,943.29 / $7,723.89
| Facility | | $4,943.29 | $4,943.29 | $7,723.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,280.22 / $6,394.51 / $7,742.77
| Professional | | $4,280.22 | $6,394.51 | $7,742.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,835.51 / $6,835.51 / $6,835.51
| Facility | | $6,835.51 | $6,835.51 | $6,835.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,835.51 / $6,835.51 / $6,835.51
| Professional | | $6,835.51 | $6,835.51 | $6,835.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $4,938.58
| Facility | | $4,938.58 | $4,938.58 | $4,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $3,605.16 / $4,938.58
| Professional | | $3,605.16 | $3,605.16 | $4,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,370.23 / $4,400.64 / $5,997.63
| Professional | | $2,370.23 | $4,400.64 | $5,997.63 |