- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $5,754.40
| Facility | | $3,981.07 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,073.80 / $6,025.60
| Professional | | $2,630.27 | $4,073.80 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Professional | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $6,760.83
| Professional | | $5,011.87 | $5,623.41 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,754.40 / $7,244.36
| Professional | | $5,248.07 | $5,754.40 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,786.30 / $7,244.36
| Professional | | $2,398.83 | $4,786.30 | $7,244.36 |