- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,048.54 / $7,048.54 / $7,048.54
| Facility | | $7,048.54 | $7,048.54 | $7,048.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,048.54 / $9,477.42 / $13,028.21
| Professional | | $7,048.54 | $9,477.42 | $13,028.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,773.17 / $13,847.37 / $19,180.41
| Facility | | $11,773.17 | $13,847.37 | $19,180.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,108.58 / $10,108.58 / $16,795.04
| Professional | | $10,108.58 | $10,108.58 | $16,795.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,522.72 / $17,645.98 / $25,126.34
| Professional | | $17,522.72 | $17,645.98 | $25,126.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,795.04 / $19,180.41 / $19,180.41
| Professional | | $16,795.04 | $19,180.41 | $19,180.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,648.52 / $11,023.07 / $19,180.41
| Professional | | $8,648.52 | $11,023.07 | $19,180.41 |