- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,768.67 / $8,234.60 / $9,638.70
| Facility | | $7,768.67 | $8,234.60 | $9,638.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,932.62 / $8,234.60 / $12,085.86
| Professional | | $6,932.62 | $8,234.60 | $12,085.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,458.04 / $16,238.11 / $28,916.08
| Facility | | $14,458.04 | $16,238.11 | $28,916.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,683.60 / $8,832.85 / $12,189.33
| Professional | | $8,683.60 | $8,832.85 | $12,189.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,907.40 / $9,907.40 / $9,907.40
| Facility | | $9,907.40 | $9,907.40 | $9,907.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,232.40 / $9,764.87 / $10,204.62
| Professional | | $7,232.40 | $9,764.87 | $10,204.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,010.80 / $8,028.76 / $11,439.71
| Professional | | $6,010.80 | $8,028.76 | $11,439.71 |