- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,103.04 / $6,103.04 / $6,103.04
| Facility | | $6,103.04 | $6,103.04 | $6,103.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,068.04 / $5,068.04 / $6,103.04
| Professional | | $5,068.04 | $5,068.04 | $6,103.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,294.28 / $10,876.44 / $11,064.42
| Professional | | $9,294.28 | $10,876.44 | $11,064.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,435.00 / $9,529.35 / $11,982.45
| Professional | | $9,435.00 | $9,529.35 | $11,982.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.50 / $6,103.04 / $6,464.83
| Facility | | $362.50 | $6,103.04 | $6,464.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,239.84 / $3,330.69 / $4,996.04
| Professional | | $2,239.84 | $3,330.69 | $4,996.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.80 / $2,902.53 / $4,996.04
| Professional | | $1,409.80 | $2,902.53 | $4,996.04 |