- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,333.12 / $6,377.60 / $7,979.68
| Facility | | $6,333.12 | $6,377.60 | $7,979.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,233.27 / $6,333.12 / $9,000.28
| Professional | | $5,233.27 | $6,333.12 | $9,000.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,969.51 / $12,567.99 / $23,939.02
| Facility | | $11,969.51 | $12,567.99 | $23,939.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,312.49 / $7,312.49 / $9,784.71
| Professional | | $7,312.49 | $7,312.49 | $9,784.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.18 / $8,121.18 / $8,121.18
| Facility | | $8,121.18 | $8,121.18 | $8,121.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,928.46 / $5,928.46 / $14,554.13
| Professional | | $5,928.46 | $5,928.46 | $14,554.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,976.22 / $6,001.71 / $9,368.20
| Professional | | $4,976.22 | $6,001.71 | $9,368.20 |