- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,443.16 / $7,443.16 / $7,443.16
| Facility | | $7,443.16 | $7,443.16 | $7,443.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,097.46 / $8,158.20 / $8,158.20
| Professional | | $7,097.46 | $8,158.20 | $8,158.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,565.52 / $11,309.82 / $11,591.16
| Professional | | $9,565.52 | $11,309.82 | $11,591.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,291.63 / $11,404.54 / $14,340.36
| Professional | | $11,291.63 | $11,404.54 | $14,340.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,134.29 / $7,443.16 / $42,111.30
| Facility | | $4,134.29 | $7,443.16 | $42,111.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,020.92 / $6,031.39 / $8,151.38
| Professional | | $4,020.92 | $6,031.39 | $8,151.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,680.62 / $6,031.39 / $8,273.65
| Professional | | $2,680.62 | $6,031.39 | $8,273.65 |