- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,290.60 / $11,290.60 / $13,548.80
| Facility | | $11,290.60 | $11,290.60 | $13,548.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,906.96 / $5,871.31 / $11,290.64
| Professional | | $4,906.96 | $5,871.31 | $11,290.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,151.10 / $11,151.10 / $11,848.05
| Professional | | $11,151.10 | $11,151.10 | $11,848.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $6,418.77 / $7,551.49
| Professional | | $6,418.77 | $6,418.77 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,290.18 / $15,290.18 / $47,193.14
| Professional | | $15,290.18 | $15,290.18 | $47,193.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,861.62 / $5,792.43 / $13,952.03
| Professional | | $3,861.62 | $5,792.43 | $13,952.03 |