- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,051.81 / $7,051.81 / $7,051.81
| Facility | | $7,051.81 | $7,051.81 | $7,051.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,051.81 / $8,484.91 / $8,484.91
| Professional | | $7,051.81 | $8,484.91 | $8,484.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,062.56 / $10,715.15 / $10,981.70
| Professional | | $9,062.56 | $10,715.15 | $10,981.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,743.88 / $11,861.31 / $14,914.72
| Professional | | $11,743.88 | $11,861.31 | $14,914.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,055.16 / $7,546.62 / $46,975.22
| Facility | | $5,055.16 | $7,546.62 | $46,975.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,861.40 / $6,785.27 / $7,838.63
| Professional | | $3,861.40 | $6,785.27 | $7,838.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,015.68 / $4,835.53 / $7,722.79
| Professional | | $3,015.68 | $4,835.53 | $7,722.79 |