- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,309.57 / $11,220.18
| Professional | | $4,786.30 | $6,309.57 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $15,135.61
| Facility | | $7,244.36 | $7,244.36 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $13,182.57
| Professional | | $7,762.47 | $7,762.47 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $19,952.62 / $19,952.62
| Facility | | $8,709.64 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $60,255.96
| Professional | | $6,309.57 | $6,309.57 | $60,255.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,244.36 / $12,882.50
| Facility | | $4,466.84 | $7,244.36 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,585.78 / $9,772.37
| Professional | | $5,495.41 | $7,585.78 | $9,772.37 |