- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $12,589.25
| Facility | | $7,943.28 | $7,943.28 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,762.47 / $12,589.25
| Professional | | $6,165.95 | $7,762.47 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $9,332.54
| Professional | | $6,918.31 | $6,918.31 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $11,481.54 / $19,498.45
| Facility | | $7,244.36 | $11,481.54 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,079.46 / $10,964.78
| Professional | | $4,786.30 | $7,079.46 | $10,964.78 |