- 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
- $2,089.30 / $2,570.40 / $5,754.40
| Professional | | $2,089.30 | $2,570.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $4,073.80
| Professional | | $1,698.24 | $2,238.72 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,951.21 / $4,570.88
| Professional | | $331.13 | $2,951.21 | $4,570.88 |
- 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
- $1,905.46 / $2,691.53 / $4,570.88
| Professional | | $1,905.46 | $2,691.53 | $4,570.88 |