- 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
- $2,884.03 / $3,715.35 / $7,762.47
| Professional | | $2,884.03 | $3,715.35 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $5,011.87
| Professional | | $2,290.87 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $3,388.44 / $6,165.95
| Professional | | $239.88 | $3,388.44 | $6,165.95 |
- 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
- $2,511.89 / $3,715.35 / $6,025.60
| Professional | | $2,511.89 | $3,715.35 | $6,025.60 |