- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,082.05 / $4,810.22 / $9,765.23
| Facility | | $3,082.05 | $4,810.22 | $9,765.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.51 / $2,956.24 / $4,297.55
| Professional | | $2,501.51 | $2,956.24 | $4,297.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,096.92 / $3,096.92 / $7,147.70
| Facility | | $3,096.92 | $3,096.92 | $7,147.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,096.92 / $3,096.92 / $4,700.54
| Professional | | $3,096.92 | $3,096.92 | $4,700.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $4,672.55
| Professional | | $3,855.99 | $4,536.46 | $4,672.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,175.73 / $2,865.06 / $4,060.29
| Professional | | $2,175.73 | $2,865.06 | $4,060.29 |