- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,381.52 / $7,381.52 / $7,538.21
| Facility | | $7,381.52 | $7,381.52 | $7,538.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,100.95 / $7,112.72 / $8,820.61
| Professional | | $5,100.95 | $7,112.72 | $8,820.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,435.34 / $1,435.34 / $1,435.34
| Facility | | $1,435.34 | $1,435.34 | $1,435.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,375.04 / $8,568.60 / $8,913.34
| Professional | | $6,375.04 | $8,568.60 | $8,913.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.70 / $7,447.14 / $7,447.14
| Professional | | $899.70 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,688.19 / $3,872.25 / $6,539.13
| Professional | | $2,688.19 | $3,872.25 | $6,539.13 |