- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,918.31 / $6,918.31
| Facility | | $3,981.07 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,073.80 / $6,606.93
| Professional | | $3,311.31 | $4,073.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,623.41
| Professional | | $4,265.80 | $4,265.80 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,570.88
| Professional | | $3,715.35 | $3,715.35 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $13,803.84
| Professional | | $4,897.79 | $8,128.31 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $8,128.31 / $8,128.31
| Professional | | $7,762.47 | $8,128.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.62 / $4,677.35 / $5,495.41
| Facility | | $5.62 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $5,370.32
| Professional | | $3,162.28 | $3,467.37 | $5,370.32 |