- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,306.76 / $4,306.76 / $4,306.76
| Facility | | $4,306.76 | $4,306.76 | $4,306.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,616.01 / $2,616.01 / $2,870.13
| Professional | | $2,616.01 | $2,616.01 | $2,870.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.83 / $2,168.86 / $3,018.28
| Facility | | $1,239.83 | $2,168.86 | $3,018.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.08 / $1,352.34 / $1,724.25
| Professional | | $1,202.08 | $1,352.34 | $1,724.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,927.21 / $2,890.82 / $4,250.93
| Facility | | $1,927.21 | $2,890.82 | $4,250.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,401.83 / $2,031.22 / $3,561.80
| Facility | | $1,401.83 | $2,031.22 | $3,561.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.77 / $878.43 / $1,497.58
| Professional | | $86.77 | $878.43 | $1,497.58 |