- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,013.62 / $10,013.62 / $10,226.21
| Facility | | $10,013.62 | $10,013.62 | $10,226.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,919.86 / $9,649.01 / $11,965.89
| Professional | | $6,919.86 | $9,649.01 | $11,965.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.16 / $1,947.16 / $1,947.16
| Facility | | $1,947.16 | $1,947.16 | $1,947.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,739.33 / $8,648.29 / $10,654.90
| Professional | | $7,739.33 | $8,648.29 | $10,654.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.52 / $10,102.62 / $10,102.62
| Professional | | $1,220.52 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,646.75 / $5,253.07 / $8,525.29
| Professional | | $3,646.75 | $5,253.07 | $8,525.29 |