- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,789.30 / $7,789.30 / $7,954.65
| Facility | | $7,789.30 | $7,789.30 | $7,954.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,382.74 / $7,505.68 / $9,307.90
| Professional | | $5,382.74 | $7,505.68 | $9,307.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,154.07 / $12,399.41 / $12,399.41
| Facility | | $7,154.07 | $12,399.41 | $12,399.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,970.30 / $6,727.30 / $8,288.18
| Professional | | $5,970.30 | $6,727.30 | $8,288.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,646.22 / $4,343.04 / $14,831.25
| Professional | | $2,646.22 | $4,343.04 | $14,831.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,996.57 / $4,077.44 / $6,675.47
| Professional | | $2,996.57 | $4,077.44 | $6,675.47 |