- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,778.45 / $4,778.45 / $4,778.45
| Facility | | $4,778.45 | $4,778.45 | $4,778.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,278.49 / $4,433.64 / $4,788.33
| Professional | | $4,278.49 | $4,433.64 | $4,788.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,857.64 / $4,857.64 / $4,857.64
| Professional | | $4,857.64 | $4,857.64 | $4,857.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,687.89 / $5,687.89 / $5,687.89
| Facility | | $5,687.89 | $5,687.89 | $5,687.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.71 / $4,834.71 / $5,687.89
| Professional | | $4,834.71 | $4,834.71 | $5,687.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,390.51 / $6,390.51 / $6,390.51
| Facility | | $6,390.51 | $6,390.51 | $6,390.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,390.51 / $6,390.51 / $9,045.04
| Professional | | $6,390.51 | $6,390.51 | $9,045.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,743.13 / $4,904.85 / $7,124.41
| Professional | | $3,743.13 | $4,904.85 | $7,124.41 |