- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,368.86 / $7,368.86 / $7,368.86
| Facility | | $7,368.86 | $7,368.86 | $7,368.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,171.09 / $5,321.58 / $11,150.46
| Professional | | $4,171.09 | $5,321.58 | $11,150.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $6,418.77 / $8,203.02
| Professional | | $6,418.77 | $6,418.77 | $8,203.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36,086.91 / $36,086.91 / $36,086.91
| Professional | | $36,086.91 | $36,086.91 | $36,086.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,131.76 / $8,820.20 / $9,378.77
| Professional | | $7,131.76 | $8,820.20 | $9,378.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,510.53 / $6,615.16 / $11,934.64
| Professional | | $5,510.53 | $6,615.16 | $11,934.64 |