- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,057.51 / $11,057.51 / $11,292.21
| Facility | | $11,057.51 | $11,057.51 | $11,292.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,641.21 / $10,654.88 / $13,213.29
| Professional | | $7,641.21 | $10,654.88 | $13,213.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,843.34 / $4,843.34 / $4,843.34
| Facility | | $4,843.34 | $4,843.34 | $4,843.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.83 / $12,835.77 / $13,370.01
| Professional | | $9,549.83 | $12,835.77 | $13,370.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.76 / $11,155.72 / $11,155.72
| Professional | | $1,347.76 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,026.91 / $5,914.35 / $9,578.37
| Professional | | $4,026.91 | $5,914.35 | $9,578.37 |