- 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
- $2,630.27 / $3,890.45 / $9,549.93
| Professional | | $2,630.27 | $3,890.45 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $6,165.95
| Professional | | $2,570.40 | $3,467.37 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $3,548.13 / $7,413.10
| Professional | | $363.08 | $3,548.13 | $7,413.10 |
- 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
- $1,819.70 / $4,466.84 / $7,762.47
| Professional | | $1,819.70 | $4,466.84 | $7,762.47 |