- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,309.57 / $10,232.93
| Professional | | $4,786.30 | $6,309.57 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $8,709.64 / $13,803.84
| Facility | | $7,244.36 | $8,709.64 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $8,709.64
| Professional | | $6,309.57 | $6,309.57 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,912.51 / $14,454.40 / $19,952.62
| Professional | | $8,912.51 | $14,454.40 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $13,489.63
| Professional | | $13,489.63 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,317.64 / $13,803.84
| Facility | | $4,466.84 | $8,317.64 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,079.46 / $10,715.19
| Professional | | $5,888.44 | $7,079.46 | $10,715.19 |