- 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
- $2,290.87 / $3,548.13 / $8,317.64
| Professional | | $2,290.87 | $3,548.13 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $5,623.41
| Professional | | $2,238.72 | $2,951.21 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $3,090.30 / $6,456.54
| Professional | | $537.03 | $3,090.30 | $6,456.54 |
- 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
- $1,862.09 / $3,801.89 / $6,760.83
| Professional | | $1,862.09 | $3,801.89 | $6,760.83 |