- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,056.16 / $9,056.16 / $9,056.16
| Facility | | $9,056.16 | $9,056.16 | $9,056.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,573.21 / $10,137.87 / $11,320.20
| Professional | | $7,573.21 | $10,137.87 | $11,320.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,781.59 / $5,781.59 / $8,487.64
| Professional | | $5,781.59 | $5,781.59 | $8,487.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,546.80 / $7,546.80 / $9,056.16
| Facility | | $7,546.80 | $7,546.80 | $9,056.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,565.91 / $6,037.44 / $10,062.40
| Professional | | $2,565.91 | $6,037.44 | $10,062.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $5,974.80 / $8,553.04
| Professional | | $2,113.10 | $5,974.80 | $8,553.04 |