- 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
- $2,187.76 / $3,090.30 / $7,762.47
| Professional | | $2,187.76 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $5,011.87
| Professional | | $2,089.30 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $3,019.95 / $6,025.60
| Professional | | $302.00 | $3,019.95 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,548.13 / $6,165.95
| Professional | | $2,187.76 | $3,548.13 | $6,165.95 |