- 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
- $2,344.23 / $3,090.30 / $6,760.83
| Professional | | $2,344.23 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,786.30
| Professional | | $1,995.26 | $2,691.53 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,548.13 / $5,370.32
| Professional | | $331.13 | $3,548.13 | $5,370.32 |
- 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
- $2,344.23 / $3,311.31 / $5,495.41
| Professional | | $2,344.23 | $3,311.31 | $5,495.41 |