- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $8,317.64
| Professional | | $4,265.80 | $4,897.79 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $7,079.46
| Professional | | $5,623.41 | $5,623.41 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,760.83 / $6,760.83 / $8,128.31
| Professional | | $6,760.83 | $6,760.83 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $14,454.40 / $19,952.62
| Professional | | $6,606.93 | $14,454.40 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Facility | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,011.87 / $7,585.78
| Professional | | $3,311.31 | $5,011.87 | $7,585.78 |