- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,705.42 / $9,705.42 / $15,164.72
| Facility | | $9,705.42 | $9,705.42 | $15,164.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,110.49 / $14,979.60 / $18,481.47
| Professional | | $9,110.49 | $14,979.60 | $18,481.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,420.53 / $13,420.53 / $13,420.53
| Facility | | $13,420.53 | $13,420.53 | $13,420.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,420.53 / $13,420.53 / $13,420.53
| Professional | | $13,420.53 | $13,420.53 | $13,420.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $11,736.82
| Facility | | $11,736.82 | $11,736.82 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $8,567.87 / $11,736.82
| Professional | | $8,567.87 | $8,567.87 | $11,736.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,657.59 / $8,980.34 / $13,680.05
| Professional | | $5,657.59 | $8,980.34 | $13,680.05 |