- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,794.15 / $7,794.15 / $7,794.15
| Facility | | $7,794.15 | $7,794.15 | $7,794.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $7,794.16
| Professional | | $5,075.03 | $5,075.03 | $7,794.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,087.60 / $13,596.44 / $17,543.38
| Facility | | $10,087.60 | $13,596.44 | $17,543.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,298.52 / $4,298.52 / $4,298.52
| Professional | | $4,298.52 | $4,298.52 | $4,298.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,911.94 / $5,911.94 / $5,911.94
| Professional | | $5,911.94 | $5,911.94 | $5,911.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,934.23 / $8,593.20 / $15,927.80
| Professional | | $6,934.23 | $8,593.20 | $15,927.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,736.78 / $4,404.95 / $5,231.49
| Professional | | $3,736.78 | $4,404.95 | $5,231.49 |