- 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
- $4,168.69 / $5,128.61 / $12,022.64
| Professional | | $4,168.69 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,165.95 / $9,120.11
| Professional | | $4,677.35 | $6,165.95 | $9,120.11 |
- 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
- $1,148.15 / $6,309.57 / $12,022.64
| Professional | | $1,148.15 | $6,309.57 | $12,022.64 |
- 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
- $4,168.69 / $5,623.41 / $10,471.29
| Professional | | $4,168.69 | $5,623.41 | $10,471.29 |