- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,833.06 / $3,833.06 / $9,856.44
| Facility | | $3,833.06 | $3,833.06 | $9,856.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,833.06 / $3,833.06 / $5,147.25
| Professional | | $3,833.06 | $3,833.06 | $5,147.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,242.45 / $11,033.74 / $12,320.55
| Professional | | $8,242.45 | $11,033.74 | $12,320.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,292.06 / $6,292.06 / $9,237.03
| Professional | | $6,292.06 | $6,292.06 | $9,237.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,285.48 / $4,161.60 / $9,856.44
| Facility | | $3,285.48 | $4,161.60 | $9,856.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.66 / $6,570.96 / $10,951.60
| Professional | | $2,792.66 | $6,570.96 | $10,951.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.84 / $6,502.79 / $7,939.91
| Professional | | $2,299.84 | $6,502.79 | $7,939.91 |