- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $6,918.31
| Professional | | $2,454.71 | $2,818.38 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,754.23 / $4,466.84
| Professional | | $2,454.71 | $2,754.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $5,754.40
| Professional | | $3,090.30 | $3,890.45 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $33,113.11
| Facility | | $4,466.84 | $8,128.31 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $6,025.60
| Professional | | $2,398.83 | $3,235.94 | $6,025.60 |