- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,878.04 / $7,657.35 / $7,719.67
| Facility | | $6,878.04 | $7,657.35 | $7,719.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,137.48 / $2,200.98
| Professional | | $2,116.32 | $2,137.48 | $2,200.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.57 / $2,113.23 / $2,232.86
| Facility | | $2,062.57 | $2,113.23 | $2,232.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.53 / $2,116.32 / $2,116.32
| Facility | | $1,996.53 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.32 / $2,116.32 / $2,116.32
| Professional | | $2,116.32 | $2,116.32 | $2,116.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.50 / $2,116.32 / $2,116.32
| Professional | | $596.50 | $2,116.32 | $2,116.32 |