- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,238.25 / $6,238.25 / $6,370.65
| Facility | | $6,238.25 | $6,238.25 | $6,370.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,972.91 / $5,851.38 / $7,454.48
| Professional | | $3,972.91 | $5,851.38 | $7,454.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,213.06 / $2,862.52 / $3,301.44
| Facility | | $1,213.06 | $2,862.52 | $3,301.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,028.67 / $5,387.72 / $6,637.84
| Professional | | $5,028.67 | $5,387.72 | $6,637.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.57 / $4,321.80 / $4,321.80
| Facility | | $775.57 | $4,321.80 | $4,321.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,673.53 / $3,673.53 / $11,880.00
| Professional | | $3,673.53 | $3,673.53 | $11,880.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.84 / $3,265.52 / $5,442.53
| Professional | | $2,271.84 | $3,265.52 | $5,442.53 |