- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,442.75 / $4,442.75 / $4,442.75
| Facility | | $4,442.75 | $4,442.75 | $4,442.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,189.35 / $4,731.09 / $5,833.70
| Professional | | $4,189.35 | $4,731.09 | $5,833.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,472.14 / $6,553.03 / $12,089.57
| Facility | | $6,472.14 | $6,553.03 | $12,089.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $4,783.71 / $10,586.05
| Professional | | $4,783.71 | $4,783.71 | $10,586.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,044.72 / $11,122.40 / $15,837.34
| Professional | | $11,044.72 | $11,122.40 | $15,837.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,507.04 / $12,089.57 / $12,089.57
| Professional | | $11,507.04 | $12,089.57 | $12,089.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,523.51 / $6,031.36 / $11,098.82
| Professional | | $4,523.51 | $6,031.36 | $11,098.82 |