- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $9,772.37 / $15,135.61
| Facility | | $9,772.37 | $9,772.37 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,585.78 / $9,772.37 / $15,135.61
| Professional | | $7,585.78 | $9,772.37 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $13,489.63
| Facility | | $13,489.63 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $13,489.63
| Professional | | $13,489.63 | $13,489.63 | $13,489.63 |
- 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 / $11,748.98
| Professional | | $8,511.38 | $8,511.38 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $13,803.84 / $22,908.68
| Facility | | $8,912.51 | $13,803.84 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $8,511.38 / $13,182.57
| Professional | | $5,623.41 | $8,511.38 | $13,182.57 |