- 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
- $2,570.40 / $3,162.28 / $6,918.31
| Professional | | $2,570.40 | $3,162.28 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $5,011.87
| Professional | | $2,089.30 | $2,754.23 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,884.03 / $5,623.41
| Professional | | $331.13 | $2,884.03 | $5,623.41 |
- 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
- $2,137.96 / $3,311.31 / $5,623.41
| Professional | | $2,137.96 | $3,311.31 | $5,623.41 |