- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,240.61 / $9,240.61 / $9,240.61
| Facility | | $9,240.61 | $9,240.61 | $9,240.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,669.37 / $7,669.37 / $9,240.61
| Professional | | $7,669.37 | $7,669.37 | $9,240.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,071.26 / $15,296.37 / $15,560.76
| Professional | | $13,071.26 | $15,296.37 | $15,560.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,267.50 / $13,400.18 / $16,849.73
| Professional | | $13,267.50 | $13,400.18 | $16,849.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,104.06 / $9,240.61 / $13,734.13
| Facility | | $6,104.06 | $9,240.61 | $13,734.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,926.57 / $5,427.89 / $7,793.80
| Professional | | $2,926.57 | $5,427.89 | $7,793.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.57 / $5,195.87 / $7,630.06
| Professional | | $1,287.57 | $5,195.87 | $7,630.06 |