- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,642.94 / $10,751.73 / $13,467.23
| Facility | | $10,642.94 | $10,751.73 | $13,467.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,046.94 / $10,751.73 / $15,723.86
| Professional | | $9,046.94 | $10,751.73 | $15,723.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,628.43 / $22,173.81 / $41,012.96
| Facility | | $20,628.43 | $22,173.81 | $41,012.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,303.16 / $11,303.16 / $16,780.65
| Professional | | $11,303.16 | $11,303.16 | $16,780.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,752.32 / $12,752.32 / $12,752.32
| Facility | | $12,752.32 | $12,752.32 | $12,752.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,309.19 / $12,752.32 / $13,594.61
| Professional | | $9,309.19 | $12,752.32 | $13,594.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,870.55 / $10,484.29 / $15,566.25
| Professional | | $7,870.55 | $10,484.29 | $15,566.25 |