- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,215.44 / $7,659.46 / $10,878.66
| Facility | | $7,215.44 | $7,659.46 | $10,878.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,845.07 / $7,659.46 / $11,100.67
| Professional | | $5,845.07 | $7,659.46 | $11,100.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,620.18 / $19,851.33 / $27,903.75
| Facility | | $11,620.18 | $19,851.33 | $27,903.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,924.55 / $9,478.83 / $9,478.83
| Professional | | $7,924.55 | $9,478.83 | $9,478.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,077.06 / $9,077.06 / $9,077.06
| Facility | | $9,077.06 | $9,077.06 | $9,077.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,626.25 / $9,077.06 / $9,077.06
| Professional | | $6,626.25 | $9,077.06 | $9,077.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,074.64 / $6,922.74 / $9,418.33
| Professional | | $4,074.64 | $6,922.74 | $9,418.33 |