- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,433.02 / $6,433.02 / $6,433.02
| Facility | | $6,433.02 | $6,433.02 | $6,433.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,433.02 / $8,584.52 / $11,555.46
| Professional | | $6,433.02 | $8,584.52 | $11,555.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,594.44 / $12,562.99 / $17,505.43
| Facility | | $10,594.44 | $12,562.99 | $17,505.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,170.98 / $9,170.98 / $15,328.38
| Professional | | $9,170.98 | $9,170.98 | $15,328.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,992.52 / $16,105.00 / $22,932.13
| Professional | | $15,992.52 | $16,105.00 | $22,932.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,095.15 / $17,505.43 / $17,505.43
| Professional | | $17,095.15 | $17,505.43 | $17,505.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,074.63 / $9,590.17 / $17,505.43
| Professional | | $8,074.63 | $9,590.17 | $17,505.43 |