- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,581.72 / $4,671.56 / $4,671.56
| Facility | | $4,581.72 | $4,671.56 | $4,671.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,066.13 / $4,671.56 / $8,025.65
| Professional | | $4,066.13 | $4,671.56 | $8,025.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,424.59 / $9,704.67 / $9,704.67
| Professional | | $6,424.59 | $9,704.67 | $9,704.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,943.14 / $7,261.93 / $7,261.93
| Facility | | $4,943.14 | $7,261.93 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $7,261.93
| Professional | | $5,301.21 | $5,301.21 | $7,261.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,848.38 / $48,028.87 / $48,511.09
| Facility | | $16,848.38 | $48,028.87 | $48,511.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52,297.82 / $52,297.82 / $69,356.55
| Professional | | $52,297.82 | $52,297.82 | $69,356.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,586.34 / $5,379.50 / $7,108.70
| Professional | | $3,586.34 | $5,379.50 | $7,108.70 |