- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,071.33 / $9,342.12 / $12,678.90
| Facility | | $9,071.33 | $9,342.12 | $12,678.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,676.08 / $9,342.12 / $9,342.12
| Professional | | $6,676.08 | $9,342.12 | $9,342.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,671.03 / $9,477.51 / $10,991.35
| Professional | | $6,671.03 | $9,477.51 | $10,991.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,587.41 / $10,587.41 / $10,587.41
| Facility | | $10,587.41 | $10,587.41 | $10,587.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,109.60 / $10,777.03 / $14,530.87
| Professional | | $7,109.60 | $10,777.03 | $14,530.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $1,546.22 / $1,546.22
| Professional | | $200.00 | $1,546.22 | $1,546.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,219.08 / $6,507.39 / $10,775.87
| Professional | | $5,219.08 | $6,507.39 | $10,775.87 |