- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $8,511.38
| Facility | | $7,079.46 | $7,079.46 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,495.41 / $9,120.11
| Professional | | $4,265.80 | $5,495.41 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,715.19 / $11,748.98
| Professional | | $8,128.31 | $10,715.19 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $14,791.08
| Professional | | $11,748.98 | $11,748.98 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $8,511.38 / $46,773.51
| Facility | | $5,011.87 | $8,511.38 | $46,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $9,772.37
| Professional | | $3,890.45 | $4,786.30 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $14,791.08 / $14,791.08
| Facility | | $6,025.60 | $14,791.08 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,760.83 / $10,964.78
| Professional | | $3,548.13 | $6,760.83 | $10,964.78 |