- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $10,964.78
| Professional | | $3,981.07 | $5,888.44 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Professional | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $7,585.78
| Professional | | $6,456.54 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $10,000.00 / $16,218.10
| Professional | | $7,762.47 | $10,000.00 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $13,803.84 / $14,125.38
| Facility | | $7,413.10 | $13,803.84 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $8,912.51 / $14,125.38
| Professional | | $5,495.41 | $8,912.51 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Professional | | $11,220.18 | $11,220.18 | $11,220.18 |