- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,897.79 / $6,918.31
| Professional | | $4,570.88 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $7,079.46
| Professional | | $5,888.44 | $5,888.44 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,918.31
| Professional | | $4,897.79 | $4,897.79 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $14,454.40 / $19,952.62
| Professional | | $6,606.93 | $14,454.40 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Facility | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,011.87 / $7,585.78
| Professional | | $3,311.31 | $5,011.87 | $7,585.78 |