- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.57 / $4,026.10 / $4,908.26
| Facility | | $3,813.57 | $4,026.10 | $4,908.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,453.75 / $3,870.57 / $6,082.33
| Professional | | $3,453.75 | $3,870.57 | $6,082.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,037.63 / $7,987.80 / $14,075.26
| Facility | | $7,037.63 | $7,987.80 | $14,075.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,279.66 / $4,279.66 / $5,905.93
| Professional | | $4,279.66 | $4,279.66 | $5,905.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $7,753.37
| Professional | | $3,429.16 | $3,429.16 | $7,753.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.83 / $4,019.12 / $5,630.11
| Professional | | $2,925.83 | $4,019.12 | $5,630.11 |