- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,548.58 / $7,548.58 / $7,548.58
| Facility | | $7,548.58 | $7,548.58 | $7,548.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,548.58 / $8,613.23 / $8,613.23
| Professional | | $7,548.58 | $8,613.23 | $8,613.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,700.98 / $11,469.98 / $11,755.31
| Professional | | $9,700.98 | $11,469.98 | $11,755.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,921.25 / $12,040.46 / $15,139.99
| Professional | | $11,921.25 | $12,040.46 | $15,139.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,526.18 / $8,047.56 / $48,028.27
| Facility | | $4,526.18 | $8,047.56 | $48,028.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,133.42 / $6,902.48 / $8,390.83
| Professional | | $4,133.42 | $6,902.48 | $8,390.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,067.77 / $6,902.48 / $10,947.27
| Professional | | $3,067.77 | $6,902.48 | $10,947.27 |