- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,461.96 / $3,461.96 / $3,461.96
| Facility | | $3,461.96 | $3,461.96 | $3,461.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,461.96 / $4,561.59 / $6,446.80
| Professional | | $3,461.96 | $4,561.59 | $6,446.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,480.81 / $7,503.37 / $9,420.65
| Facility | | $5,480.81 | $7,503.37 | $9,420.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,477.46 / $8,249.04
| Professional | | $5,477.46 | $5,477.46 | $8,249.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,606.45 / $8,667.00 / $12,341.05
| Professional | | $8,606.45 | $8,667.00 | $12,341.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,199.86 / $9,420.65 / $9,420.65
| Professional | | $9,199.86 | $9,420.65 | $9,420.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,345.39 / $5,085.95 / $9,420.65
| Professional | | $4,345.39 | $5,085.95 | $9,420.65 |