- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,321.58 / $5,904.74 / $7,368.86
| Facility | | $5,321.58 | $5,904.74 | $7,368.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,469.92 / $5,871.31 / $7,573.52
| Professional | | $4,469.92 | $5,871.31 | $7,573.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.53 / $10,569.91 / $25,860.87
| Facility | | $8,121.53 | $10,569.91 | $25,860.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,161.44 / $11,151.10 / $13,713.17
| Professional | | $10,161.44 | $11,151.10 | $13,713.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $6,418.77 / $7,551.49
| Professional | | $6,418.77 | $6,418.77 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,632.46 / $7,020.97 / $13,952.03
| Professional | | $4,632.46 | $7,020.97 | $13,952.03 |