- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,798.05 / $6,798.05 / $6,934.68
| Facility | | $6,798.05 | $6,798.05 | $6,934.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,233.34 / $6,349.72 / $8,270.41
| Professional | | $5,233.34 | $6,349.72 | $8,270.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.38 / $1,477.38 / $1,477.38
| Facility | | $1,477.38 | $1,477.38 | $1,477.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,880.84 / $5,076.80 / $6,442.45
| Professional | | $4,880.84 | $5,076.80 | $6,442.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Facility | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.99 / $7,860.06 / $7,860.06
| Professional | | $935.99 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.04 / $3,837.36 / $6,274.56
| Professional | | $2,762.04 | $3,837.36 | $6,274.56 |