- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,056.63 / $5,056.63 / $5,056.63
| Facility | | $5,056.63 | $5,056.63 | $5,056.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,056.63 / $5,727.15 / $5,727.15
| Professional | | $5,056.63 | $5,727.15 | $5,727.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,498.50 / $7,683.52 / $7,874.65
| Professional | | $6,498.50 | $7,683.52 | $7,874.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,926.75 / $8,006.02 / $10,066.96
| Professional | | $7,926.75 | $8,006.02 | $10,066.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,156.41 / $5,056.63 / $33,517.87
| Facility | | $2,156.41 | $5,056.63 | $33,517.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,768.89 / $4,864.43 / $5,620.84
| Professional | | $2,768.89 | $4,864.43 | $5,620.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.96 / $4,864.43 / $5,537.77
| Professional | | $2,161.96 | $4,864.43 | $5,537.77 |