- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,192.14 / $5,192.14 / $8,112.72
| Facility | | $5,192.14 | $5,192.14 | $8,112.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,946.32 / $7,984.60 / $9,851.20
| Professional | | $4,946.32 | $7,984.60 | $9,851.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,179.62 / $7,179.62 / $7,179.62
| Facility | | $7,179.62 | $7,179.62 | $7,179.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,179.62 / $7,179.62 / $7,179.62
| Professional | | $7,179.62 | $7,179.62 | $7,179.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $6,553.03
| Facility | | $6,553.03 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $4,783.71 / $6,553.03
| Professional | | $4,783.71 | $4,783.71 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $4,622.18 / $7,253.74
| Professional | | $3,015.68 | $4,622.18 | $7,253.74 |