- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,816.03 / $1,816.03 / $4,662.77
| Facility | | $1,816.03 | $1,816.03 | $4,662.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.03 / $2,522.37 / $4,662.77
| Professional | | $1,816.03 | $2,522.37 | $4,662.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,082.05 / $3,096.92 / $6,842.11
| Professional | | $3,082.05 | $3,096.92 | $6,842.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,452.89 / $4,536.46 / $4,536.46
| Facility | | $4,452.89 | $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
- $3,117.03 / $4,660.68 / $8,071.59
| Professional | | $3,117.03 | $4,660.68 | $8,071.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.01 / $2,560.09 / $3,857.28
| Professional | | $2,367.01 | $2,560.09 | $3,857.28 |