- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,739.93 / $7,739.93 / $7,904.21
| Facility | | $7,739.93 | $7,739.93 | $7,904.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,929.16 / $7,259.94 / $9,248.93
| Professional | | $4,929.16 | $7,259.94 | $9,248.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.04 / $2,528.32 / $2,800.61
| Facility | | $1,281.04 | $2,528.32 | $2,800.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,684.62 / $8,984.67 / $9,358.74
| Professional | | $6,684.62 | $8,984.67 | $9,358.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.15 / $5,300.15 / $5,406.15
| Facility | | $5,300.15 | $5,300.15 | $5,406.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,505.13 / $5,300.15 / $6,350.40
| Professional | | $4,505.13 | $5,300.15 | $6,350.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.72 / $4,155.43 / $6,774.41
| Professional | | $2,818.72 | $4,155.43 | $6,774.41 |