- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $41,686.94 / $41,686.94
| Facility | | $5,011.87 | $41,686.94 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $5,495.41
| Professional | | $4,677.35 | $5,128.61 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,370.32 / $5,888.44
| Professional | | $4,897.79 | $5,370.32 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $11,481.54 / $25,703.96
| Facility | | $10,964.78 | $11,481.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $7,762.47 / $13,803.84
| Professional | | $7,762.47 | $7,762.47 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $8,128.31 / $8,128.31
| Facility | | $8,128.31 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,019.95 / $8,511.38
| Professional | | $2,818.38 | $3,019.95 | $8,511.38 |