- 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
- $2,754.23 / $3,311.31 / $6,918.31
| Professional | | $2,754.23 | $3,311.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $5,370.32
| Professional | | $2,238.72 | $2,951.21 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,715.35 / $6,025.60
| Professional | | $331.13 | $3,715.35 | $6,025.60 |
- 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
- $2,398.83 / $3,548.13 / $6,165.95
| Professional | | $2,398.83 | $3,548.13 | $6,165.95 |