- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,770.12 / $8,770.12 / $8,770.12
| Facility | | $8,770.12 | $8,770.12 | $8,770.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,770.12 / $8,770.12 / $9,432.70
| Professional | | $8,770.12 | $8,770.12 | $9,432.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,625.41 / $23,380.03 / $31,299.19
| Facility | | $11,625.41 | $23,380.03 | $31,299.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,625.41 / $12,519.68 / $20,782.25
| Professional | | $11,625.41 | $12,519.68 | $20,782.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,736.82 / $11,736.82 / $21,421.45
| Facility | | $11,736.82 | $11,736.82 | $21,421.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,567.87 / $11,736.82 / $89,783.83
| Professional | | $8,567.87 | $11,736.82 | $89,783.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,922.76 / $10,755.37 / $13,998.28
| Professional | | $8,922.76 | $10,755.37 | $13,998.28 |