- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $6,309.57
| Professional | | $1,621.81 | $2,454.71 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $3,801.89
| Professional | | $1,995.26 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $4,677.35
| Professional | | $2,398.83 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $33,113.11
| Facility | | $4,466.84 | $8,128.31 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $5,128.61
| Professional | | $1,819.70 | $2,754.23 | $5,128.61 |