- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $8,912.51 / $12,589.25
| Professional | | $7,762.47 | $8,912.51 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $12,589.25
| Professional | | $9,549.93 | $9,549.93 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $12,589.25
| Professional | | $8,511.38 | $8,511.38 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $25,703.96 / $35,481.34
| Professional | | $11,748.98 | $25,703.96 | $35,481.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,542.29 / $27,542.29 / $27,542.29
| Facility | | $27,542.29 | $27,542.29 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $9,120.11 / $13,489.63
| Professional | | $5,888.44 | $9,120.11 | $13,489.63 |