- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,473.09 / $5,809.90 / $8,251.74
| Facility | | $5,473.09 | $5,809.90 | $8,251.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,841.02 / $5,809.90 / $8,420.14
| Professional | | $4,841.02 | $5,809.90 | $8,420.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,814.20 / $15,057.74 / $21,165.71
| Facility | | $8,814.20 | $15,057.74 | $21,165.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,010.97 / $7,189.94 / $7,189.94
| Professional | | $6,010.97 | $7,189.94 | $7,189.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,687.89 / $5,687.89 / $5,687.89
| Facility | | $5,687.89 | $5,687.89 | $5,687.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,834.71 / $5,687.89 / $5,687.89
| Professional | | $4,834.71 | $5,687.89 | $5,687.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,027.48 / $5,307.97 / $7,202.35
| Professional | | $3,027.48 | $5,307.97 | $7,202.35 |