- 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 / $2,818.38 / $6,309.57
| Professional | | $2,290.87 | $2,818.38 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $4,466.84
| Professional | | $1,862.09 | $2,454.71 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,235.94 / $5,011.87
| Professional | | $331.13 | $3,235.94 | $5,011.87 |
- 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 / $3,019.95 / $5,011.87
| Professional | | $2,137.96 | $3,019.95 | $5,011.87 |