- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,055.69 / $8,055.69 / $8,055.69
| Facility | | $8,055.69 | $8,055.69 | $8,055.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,639.51 / $6,639.51 / $8,055.69
| Professional | | $6,639.51 | $6,639.51 | $8,055.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,645.61 / $14,798.26 / $15,054.04
| Professional | | $12,645.61 | $14,798.26 | $15,054.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,836.25 / $12,964.61 / $16,302.04
| Professional | | $12,836.25 | $12,964.61 | $16,302.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,905.28 / $7,433.65 / $12,313.16
| Facility | | $5,905.28 | $7,433.65 | $12,313.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,940.77 / $3,984.37 / $5,881.53
| Professional | | $2,940.77 | $3,984.37 | $5,881.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.56 / $3,475.22 / $5,881.53
| Professional | | $1,461.56 | $3,475.22 | $5,881.53 |