- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,085.89 / $5,185.60 / $5,185.60
| Facility | | $5,085.89 | $5,185.60 | $5,185.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,085.89 / $5,208.88 / $8,908.78
| Professional | | $5,085.89 | $5,208.88 | $8,908.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,131.55 / $10,772.56 / $10,772.56
| Professional | | $7,131.55 | $10,772.56 | $10,772.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,398.15 / $8,121.18 / $8,121.18
| Facility | | $6,398.15 | $8,121.18 | $8,121.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $8,121.18
| Professional | | $5,928.46 | $5,928.46 | $8,121.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,061.54 / $62,341.20 / $63,837.40
| Facility | | $19,061.54 | $62,341.20 | $63,837.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79,477.56 / $79,477.56 / $89,771.33
| Professional | | $79,477.56 | $79,477.56 | $89,771.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,980.97 / $5,971.46 / $8,997.16
| Professional | | $3,980.97 | $5,971.46 | $8,997.16 |