- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,561.65 / $9,561.65 / $9,561.65
| Facility | | $9,561.65 | $9,561.65 | $9,561.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,880.73 / $7,880.73 / $9,561.65
| Professional | | $7,880.73 | $7,880.73 | $9,561.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,009.61 / $17,564.68 / $17,868.28
| Professional | | $15,009.61 | $17,564.68 | $17,868.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,236.25 / $15,388.61 / $19,350.04
| Professional | | $15,236.25 | $15,388.61 | $19,350.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,009.23 / $8,823.10 / $14,615.03
| Facility | | $7,009.23 | $8,823.10 | $14,615.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,490.47 / $4,656.60 / $6,980.93
| Professional | | $3,490.47 | $4,656.60 | $6,980.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.23 / $4,124.77 / $6,980.93
| Professional | | $1,314.23 | $4,124.77 | $6,980.93 |