- 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
- $2,398.83 / $2,818.38 / $7,079.46
| Professional | | $2,398.83 | $2,818.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $4,677.35
| Professional | | $1,905.46 | $2,570.40 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,388.44 / $5,128.61
| Professional | | $331.13 | $3,388.44 | $5,128.61 |
- 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
- $2,238.72 / $3,162.28 / $5,128.61
| Professional | | $2,238.72 | $3,162.28 | $5,128.61 |