- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,818.39 / $4,818.39 / $4,818.39
| Facility | | $4,818.39 | $4,818.39 | $4,818.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,817.39 / $5,131.10 / $8,337.93
| Professional | | $4,817.39 | $5,131.10 | $8,337.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,874.68 / $8,302.44 / $13,111.76
| Facility | | $6,874.68 | $8,302.44 | $13,111.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,060.78 / $6,060.78 / $11,481.11
| Professional | | $6,060.78 | $6,060.78 | $11,481.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,978.56 / $12,062.82 / $17,176.41
| Professional | | $11,978.56 | $12,062.82 | $17,176.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,804.45 / $13,111.76 / $13,111.76
| Professional | | $12,804.45 | $13,111.76 | $13,111.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,887.18 / $7,062.14 / $12,037.25
| Professional | | $5,887.18 | $7,062.14 | $12,037.25 |