- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,099.23 / $7,099.23 / $7,454.20
| Facility | | $7,099.23 | $7,099.23 | $7,454.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.69 / $2,427.09 / $2,851.83
| Professional | | $2,123.69 | $2,427.09 | $2,851.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.16 / $968.00 / $3,488.93
| Professional | | $239.16 | $968.00 | $3,488.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,250.11 / $4,285.33 / $4,988.69
| Facility | | $4,250.11 | $4,285.33 | $4,988.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,695.30 / $3,697.59 / $4,427.39
| Professional | | $3,695.30 | $3,697.59 | $4,427.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,550.79 / $4,550.79 / $4,550.79
| Facility | | $4,550.79 | $4,550.79 | $4,550.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,820.32 / $4,247.39
| Professional | | $1,274.22 | $1,820.32 | $4,247.39 |