- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,398.63 / $4,398.63 / $4,398.63
| Facility | | $4,398.63 | $4,398.63 | $4,398.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,398.63 / $5,400.19 / $7,633.15
| Professional | | $4,398.63 | $5,400.19 | $7,633.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,201.48 / $8,121.18 / $11,969.51
| Facility | | $7,201.48 | $8,121.18 | $11,969.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $14,554.13
| Professional | | $5,928.46 | $5,928.46 | $14,554.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,935.04 / $11,011.95 / $15,680.06
| Professional | | $10,935.04 | $11,011.95 | $15,680.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,688.98 / $11,969.51 / $11,969.51
| Professional | | $11,688.98 | $11,969.51 | $11,969.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,397.10 / $6,835.66 / $11,969.51
| Professional | | $5,397.10 | $6,835.66 | $11,969.51 |