- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,727.35 / $6,727.35 / $6,727.35
| Facility | | $6,727.35 | $6,727.35 | $6,727.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,471.58 / $6,817.05 / $8,677.41
| Professional | | $5,471.58 | $6,817.05 | $8,677.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,806.73 / $10,232.45 / $11,511.52
| Professional | | $7,806.73 | $10,232.45 | $11,511.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,451.66 / $7,860.06 / $7,860.06
| Facility | | $5,451.66 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,681.05 / $7,860.06 / $7,860.06
| Professional | | $6,681.05 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $8,377.54 / $8,377.54
| Facility | | $64.00 | $8,377.54 | $8,377.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,380.42 / $3,861.08 / $5,643.12
| Professional | | $2,380.42 | $3,861.08 | $5,643.12 |