- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,025.60 / $10,232.93
| Professional | | $4,466.84 | $6,025.60 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $14,125.38
| Facility | | $6,918.31 | $6,918.31 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $12,589.25
| Professional | | $7,413.10 | $7,413.10 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $18,620.87 / $18,620.87
| Facility | | $8,128.31 | $18,620.87 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $56,234.13
| Professional | | $5,888.44 | $5,888.44 | $56,234.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $12,302.69
| Facility | | $4,466.84 | $6,918.31 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,244.36 / $9,549.93
| Professional | | $5,370.32 | $7,244.36 | $9,549.93 |