- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,566.18 / $9,566.18 / $9,566.18
| Facility | | $9,566.18 | $9,566.18 | $9,566.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,652.94 / $9,566.18 / $10,890.73
| Professional | | $7,652.94 | $9,566.18 | $10,890.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,848.27 / $7,848.27 / $15,147.16
| Facility | | $7,848.27 | $7,848.27 | $15,147.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,465.50 / $7,848.27 / $10,670.74
| Professional | | $6,465.50 | $7,848.27 | $10,670.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.67 / $1,700.84 / $2,319.33
| Facility | | $1,159.67 | $1,700.84 | $2,319.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.29 / $1,700.84 / $2,087.40
| Professional | | $1,314.29 | $1,700.84 | $2,087.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,784.57 / $10,777.03 / $11,220.40
| Professional | | $9,784.57 | $10,777.03 | $11,220.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,338.26 / $6,761.18 / $10,104.07
| Professional | | $4,338.26 | $6,761.18 | $10,104.07 |