- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,013.81 / $5,187.16 / $6,669.21
| Facility | | $5,013.81 | $5,187.16 | $6,669.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,334.09 / $5,261.13 / $7,500.44
| Professional | | $4,334.09 | $5,261.13 | $7,500.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,264.95 / $10,890.58 / $19,772.86
| Facility | | $9,264.95 | $10,890.58 | $19,772.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,445.78 / $5,539.38 / $7,644.34
| Professional | | $5,445.78 | $5,539.38 | $7,644.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,553.03 / $6,553.03 / $6,553.03
| Facility | | $6,553.03 | $6,553.03 | $6,553.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,783.71 / $6,412.20 / $6,749.62
| Professional | | $4,783.71 | $6,412.20 | $6,749.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,776.61 / $4,948.72 / $7,250.29
| Professional | | $3,776.61 | $4,948.72 | $7,250.29 |