- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,424.49 / $5,462.26 / $6,446.80
| Facility | | $5,424.49 | $5,462.26 | $6,446.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,618.60 / $5,462.26 / $8,150.19
| Professional | | $4,618.60 | $5,462.26 | $8,150.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,673.45 / $10,950.30 / $19,570.50
| Facility | | $9,673.45 | $10,950.30 | $19,570.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,886.08 / $6,543.68 / $8,546.26
| Professional | | $5,886.08 | $6,543.68 | $8,546.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $7,503.37
| Facility | | $7,503.37 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $6,806.53 / $7,998.97
| Professional | | $5,477.46 | $6,806.53 | $7,998.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,916.55 / $5,364.56 / $7,504.46
| Professional | | $3,916.55 | $5,364.56 | $7,504.46 |