- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,851.24 / $4,076.97 / $5,001.20
| Facility | | $3,851.24 | $4,076.97 | $5,001.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,633.25 / $4,050.17 / $6,394.51
| Professional | | $3,633.25 | $4,050.17 | $6,394.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,168.65 / $8,397.79 / $15,628.30
| Facility | | $7,168.65 | $8,397.79 | $15,628.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,333.72 / $4,353.79 / $6,008.23
| Professional | | $4,333.72 | $4,353.79 | $6,008.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,938.58 / $4,938.58 / $4,938.58
| Facility | | $4,938.58 | $4,938.58 | $4,938.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,605.16 / $4,938.58 / $5,086.74
| Professional | | $3,605.16 | $4,938.58 | $5,086.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,962.80 / $4,308.82 / $5,991.13
| Professional | | $2,962.80 | $4,308.82 | $5,991.13 |