- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,652.82 / $4,744.05 / $4,744.05
| Facility | | $4,652.82 | $4,744.05 | $4,744.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,353.05 / $4,744.05 / $8,150.19
| Professional | | $4,353.05 | $4,744.05 | $8,150.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,524.30 / $9,855.27 / $9,855.27
| Professional | | $6,524.30 | $9,855.27 | $9,855.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,035.70 / $7,503.37 / $7,503.37
| Facility | | $5,035.70 | $7,503.37 | $7,503.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $5,477.46 / $7,503.37
| Professional | | $5,477.46 | $5,477.46 | $7,503.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,782.91 / $48,813.24 / $48,813.24
| Facility | | $14,782.91 | $48,813.24 | $48,813.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54,698.83 / $54,698.83 / $70,654.88
| Professional | | $54,698.83 | $54,698.83 | $70,654.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,641.99 / $5,462.98 / $7,219.01
| Professional | | $3,641.99 | $5,462.98 | $7,219.01 |