- 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
- $3,090.30 / $3,801.89 / $7,079.46
| Professional | | $3,090.30 | $3,801.89 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $6,760.83
| Professional | | $3,388.44 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $4,570.88 / $8,912.51
| Professional | | $616.60 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,238.72 / $6,606.93
| Facility | | $575.44 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,168.69 / $7,762.47
| Professional | | $2,951.21 | $4,168.69 | $7,762.47 |