- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,810.08 / $8,345.12 / $8,967.89
| Facility | | $5,810.08 | $8,345.12 | $8,967.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,810.08 / $7,731.10 / $10,831.44
| Professional | | $5,810.08 | $7,731.10 | $10,831.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,685.17 / $10,685.17 / $10,685.17
| Facility | | $10,685.17 | $10,685.17 | $10,685.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,777.03 / $10,777.03 / $10,777.03
| Professional | | $10,777.03 | $10,777.03 | $10,777.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,972.10 / $10,837.05 / $13,021.19
| Professional | | $6,972.10 | $10,837.05 | $13,021.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.97 / $1,236.97 / $12,369.76
| Professional | | $1,236.97 | $1,236.97 | $12,369.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,938.57 / $6,546.43 / $9,406.79
| Professional | | $4,938.57 | $6,546.43 | $9,406.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,671.03 / $6,671.03 / $6,671.03
| Professional | | $6,671.03 | $6,671.03 | $6,671.03 |