- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,474.49 / $4,562.22 / $4,562.22
| Facility | | $4,474.49 | $4,562.22 | $4,562.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,474.49 / $4,858.34 / $7,837.82
| Professional | | $4,474.49 | $4,858.34 | $7,837.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,274.23 / $9,477.54 / $9,477.54
| Professional | | $6,274.23 | $9,477.54 | $9,477.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,629.01 / $8,136.27 / $8,136.27
| Facility | | $5,629.01 | $8,136.27 | $8,136.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,939.48 / $5,939.48 / $8,136.27
| Professional | | $5,939.48 | $5,939.48 | $8,136.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,512.55 / $54,846.88 / $56,163.20
| Facility | | $17,512.55 | $54,846.88 | $56,163.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69,923.17 / $69,923.17 / $83,730.08
| Professional | | $69,923.17 | $69,923.17 | $83,730.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,502.40 / $5,253.60 / $7,915.56
| Professional | | $3,502.40 | $5,253.60 | $7,915.56 |