- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,595.11 / $5,595.11 / $5,595.11
| Facility | | $5,595.11 | $5,595.11 | $5,595.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,536.82 / $5,595.11 / $6,017.82
| Professional | | $5,536.82 | $5,595.11 | $6,017.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,416.70 / $14,464.16 / $19,968.04
| Facility | | $7,416.70 | $14,464.16 | $19,968.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,371.42 / $7,987.22 / $12,636.72
| Professional | | $7,371.42 | $7,987.22 | $12,636.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,136.27 / $8,136.27 / $13,426.28
| Facility | | $8,136.27 | $8,136.27 | $13,426.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $8,136.27 / $56,273.64
| Professional | | $5,939.48 | $8,136.27 | $56,273.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,692.48 / $6,942.32 / $9,487.46
| Professional | | $5,692.48 | $6,942.32 | $9,487.46 |