- 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
- $2,630.27 / $3,311.31 / $7,585.78
| Professional | | $2,630.27 | $3,311.31 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,162.28 / $5,495.41
| Professional | | $2,344.23 | $3,162.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,981.07 / $5,623.41
| Professional | | $331.13 | $3,981.07 | $5,623.41 |
- 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 / $3,467.37 / $5,623.41
| Professional | | $2,398.83 | $3,467.37 | $5,623.41 |