- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,886.13 / $6,684.29 / $7,189.30
| Facility | | $5,886.13 | $6,684.29 | $7,189.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,075.03 / $5,075.03 / $5,075.03
| Professional | | $5,075.03 | $5,075.03 | $5,075.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,038.57 / $12,057.86 / $17,543.38
| Facility | | $8,038.57 | $12,057.86 | $17,543.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,675.19 / $4,839.53 / $15,294.00
| Professional | | $4,675.19 | $4,839.53 | $15,294.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,259.85 / $9,259.85 / $16,119.45
| Facility | | $9,259.85 | $9,259.85 | $16,119.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,911.94 / $5,911.94 / $5,911.94
| Professional | | $5,911.94 | $5,911.94 | $5,911.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,180.53 / $3,531.82 / $5,182.45
| Professional | | $3,180.53 | $3,531.82 | $5,182.45 |