- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,001.65 / $8,001.65 / $8,171.52
| Facility | | $8,001.65 | $8,001.65 | $8,171.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,529.50 / $7,710.29 / $9,561.65
| Professional | | $5,529.50 | $7,710.29 | $9,561.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.94 / $1,555.94 / $1,555.94
| Facility | | $1,555.94 | $1,555.94 | $1,555.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,184.26 / $6,910.64 / $8,514.07
| Professional | | $6,184.26 | $6,910.64 | $8,514.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.29 / $8,072.81 / $8,072.81
| Professional | | $975.29 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.03 / $4,279.85 / $6,584.40
| Professional | | $2,914.03 | $4,279.85 | $6,584.40 |