- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,628.49 / $3,628.49 / $3,628.49
| Facility | | $3,628.49 | $3,628.49 | $3,628.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,628.49 / $4,398.95 / $6,234.27
| Professional | | $3,628.49 | $4,398.95 | $6,234.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,957.05 / $7,957.05 / $9,873.81
| Facility | | $7,957.05 | $7,957.05 | $9,873.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,763.49 / $6,763.49 / $8,645.85
| Professional | | $6,763.49 | $6,763.49 | $8,645.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,020.45 / $9,083.91 / $12,934.69
| Professional | | $9,020.45 | $9,083.91 | $12,934.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,567.93 / $6,567.91 / $6,567.91
| Professional | | $4,567.93 | $6,567.91 | $6,567.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,147.53 / $11,938.27 / $14,325.92
| Facility | | $10,147.53 | $11,938.27 | $14,325.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,452.13 / $5,012.56 / $9,873.81
| Professional | | $4,452.13 | $5,012.56 | $9,873.81 |