- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,836.06 / $8,853.93 / $11,115.27
| Facility | | $8,836.06 | $8,853.93 | $11,115.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,629.61 / $8,853.93 / $13,107.52
| Professional | | $7,629.61 | $8,853.93 | $13,107.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,095.98 / $18,301.30 / $34,191.96
| Facility | | $17,095.98 | $18,301.30 | $34,191.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,672.80 / $5,672.80 / $14,121.61
| Professional | | $5,672.80 | $5,672.80 | $14,121.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,812.54 / $9,812.54 / $9,812.54
| Facility | | $9,812.54 | $9,812.54 | $9,812.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,340.66 / $9,812.54 / $10,106.92
| Professional | | $8,340.66 | $9,812.54 | $10,106.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,528.64 / $8,784.99 / $13,057.27
| Professional | | $6,528.64 | $8,784.99 | $13,057.27 |