- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,478.66 / $5,478.66 / $5,478.66
| Facility | | $5,478.66 | $5,478.66 | $5,478.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,478.66 / $5,769.52 / $51,380.40
| Professional | | $5,478.66 | $5,769.52 | $51,380.40 |
- 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 / $11,736.82 / $12,512.04
| Professional | | $8,567.87 | $11,736.82 | $12,512.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,453.32 / $15,247.30 / $19,821.49
| Professional | | $9,453.32 | $15,247.30 | $19,821.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,288.50 / $20,396.47 / $20,396.47
| Facility | | $18,288.50 | $20,396.47 | $20,396.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,614.46 / $14,620.19 / $21,930.29
| Professional | | $11,614.46 | $14,620.19 | $21,930.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,662.46 / $8,486.39 / $12,174.81
| Professional | | $7,662.46 | $8,486.39 | $12,174.81 |