- 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
- $3,548.13 / $4,365.16 / $10,232.93
| Professional | | $3,548.13 | $4,365.16 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,365.16 / $6,760.83
| Professional | | $3,311.31 | $4,365.16 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $5,495.41 / $8,912.51
| Professional | | $331.13 | $5,495.41 | $8,912.51 |
- 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
- $3,388.44 / $5,248.07 / $8,912.51
| Professional | | $3,388.44 | $5,248.07 | $8,912.51 |