- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,187.51 / $5,187.68 / $6,521.36
| Facility | | $5,187.51 | $5,187.68 | $6,521.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,526.18 / $5,293.43 / $7,695.18
| Professional | | $4,526.18 | $5,293.43 | $7,695.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,036.81 / $10,737.43 / $20,329.93
| Facility | | $10,036.81 | $10,737.43 | $20,329.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,539.84 / $5,635.06 / $8,411.35
| Professional | | $5,539.84 | $5,635.06 | $8,411.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $6,652.12
| Facility | | $6,652.12 | $6,652.12 | $6,652.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $6,217.38 / $6,851.68
| Professional | | $4,856.05 | $6,217.38 | $6,851.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,893.35 / $5,157.99 / $7,241.63
| Professional | | $3,893.35 | $5,157.99 | $7,241.63 |