- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,128.31 / $8,128.31
| Facility | | $6,918.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,365.16 / $4,897.79
| Professional | | $3,981.07 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,709.64 / $16,595.87
| Facility | | $4,570.88 | $8,709.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,302.68 / $26,302.68 / $26,302.68
| Professional | | $26,302.68 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $6,918.31
| Professional | | $2,290.87 | $2,454.71 | $6,918.31 |