- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,682.37 / $4,682.37 / $7,316.21
| Facility | | $4,682.37 | $4,682.37 | $7,316.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,395.35 / $6,902.97 / $7,316.21
| Professional | | $4,395.35 | $6,902.97 | $7,316.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,474.73 / $6,474.73 / $6,474.73
| Facility | | $6,474.73 | $6,474.73 | $6,474.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,474.73 / $6,474.73 / $6,474.73
| Professional | | $6,474.73 | $6,474.73 | $6,474.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $4,751.45
| Facility | | $4,751.45 | $4,751.45 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,038.73 / $4,751.45
| Professional | | $4,038.73 | $4,038.73 | $4,751.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.05 / $4,168.38 / $6,279.07
| Professional | | $2,529.05 | $4,168.38 | $6,279.07 |