- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,754.40 / $9,120.11
| Professional | | $4,365.16 | $5,754.40 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $8,128.31 / $11,481.54
| Facility | | $6,456.54 | $8,128.31 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $8,128.31
| Professional | | $5,888.44 | $5,888.44 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $12,022.64 / $16,595.87
| Professional | | $7,413.10 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,943.28 / $12,302.69
| Facility | | $4,466.84 | $7,943.28 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,888.44 / $9,120.11
| Professional | | $5,011.87 | $5,888.44 | $9,120.11 |