- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $10,232.93 / $17,782.79
| Professional | | $7,943.28 | $10,232.93 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $20,892.96
| Facility | | $12,882.50 | $12,882.50 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $12,882.50
| Professional | | $9,332.54 | $9,332.54 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $21,877.62 / $30,199.52
| Professional | | $13,489.63 | $21,877.62 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,417.38 / $20,417.38 / $20,417.38
| Professional | | $20,417.38 | $20,417.38 | $20,417.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $20,417.38 / $25,703.96
| Facility | | $12,302.69 | $20,417.38 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,332.54 / $10,715.19 / $16,982.44
| Professional | | $9,332.54 | $10,715.19 | $16,982.44 |