- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,212.12 / $8,212.12 / $8,212.12
| Facility | | $8,212.12 | $8,212.12 | $8,212.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,679.20 / $8,321.62 / $10,242.03
| Professional | | $6,679.20 | $8,321.62 | $10,242.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,221.82 / $10,349.57 / $11,039.54
| Professional | | $8,221.82 | $10,349.57 | $11,039.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,351.96 / $8,072.81 / $8,072.81
| Facility | | $6,351.96 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,861.89 / $8,072.81 / $8,072.81
| Professional | | $6,861.89 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $8,823.10 / $8,823.10
| Facility | | $64.00 | $8,823.10 | $8,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.03 / $4,279.85 / $5,731.20
| Professional | | $2,914.03 | $4,279.85 | $5,731.20 |