- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,422.76 / $7,690.05 / $7,745.48
| Facility | | $7,422.76 | $7,690.05 | $7,745.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $7,690.05 / $7,745.48
| Professional | | $6,408.38 | $7,690.05 | $7,745.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,819.92 / $6,819.92 / $6,819.92
| Facility | | $6,819.92 | $6,819.92 | $6,819.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,703.80 / $6,819.92 / $6,819.92
| Professional | | $6,703.80 | $6,819.92 | $6,819.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.89 / $6,045.64 / $6,408.38
| Facility | | $289.89 | $6,045.64 | $6,408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,408.38 / $6,408.38 / $6,408.38
| Professional | | $6,408.38 | $6,408.38 | $6,408.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,087.96 / $6,408.38 / $6,624.52
| Professional | | $6,087.96 | $6,408.38 | $6,624.52 |