- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $6,606.93
| Professional | | $2,238.72 | $2,570.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,511.89 / $4,677.35
| Professional | | $2,137.96 | $2,511.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $5,248.07
| Professional | | $2,754.23 | $3,715.35 | $5,248.07 |
- 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
- $2,238.72 / $3,235.94 / $5,495.41
| Professional | | $2,238.72 | $3,235.94 | $5,495.41 |