- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,898.26 / $8,991.25 / $10,789.50
| Facility | | $5,898.26 | $8,991.25 | $10,789.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,394.75 / $5,898.26 / $6,114.05
| Professional | | $5,394.75 | $5,898.26 | $6,114.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,912.30 / $10,789.50 / $12,587.75
| Facility | | $7,912.30 | $10,789.50 | $12,587.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,631.60 / $8,631.60 / $9,710.54
| Professional | | $8,631.60 | $8,631.60 | $9,710.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,844.31 / $8,631.60 / $21,577.20
| Facility | | $5,844.31 | $8,631.60 | $21,577.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,903.59 / $10,161.19 / $34,670.26
| Professional | | $2,903.59 | $10,161.19 | $34,670.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,021.06 / $3,021.06 / $3,021.06
| Facility | | $3,021.06 | $3,021.06 | $3,021.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $3,596.50 / $10,429.85
| Professional | | $3,021.06 | $3,596.50 | $10,429.85 |