- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,025.60 / $10,232.93
| Professional | | $4,570.88 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,317.64 / $13,489.63
| Facility | | $6,918.31 | $8,317.64 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $8,317.64
| Professional | | $6,025.60 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $14,125.38 / $19,498.45
| Professional | | $8,709.64 | $14,125.38 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,182.57 / $13,182.57 / $13,182.57
| Professional | | $13,182.57 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,943.28 / $13,489.63
| Facility | | $4,365.16 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,918.31 / $10,232.93
| Professional | | $5,495.41 | $6,918.31 | $10,232.93 |