- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,677.35 / $8,709.64
| Professional | | $3,890.45 | $4,677.35 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,623.41 / $8,317.64
| Professional | | $4,168.69 | $5,623.41 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,495.41 / $10,964.78
| Professional | | $1,318.26 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,238.72 / $6,606.93
| Facility | | $575.44 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,128.61 / $9,549.93
| Professional | | $2,951.21 | $5,128.61 | $9,549.93 |