- 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
- $2,691.53 / $2,818.38 / $6,760.83
| Professional | | $2,691.53 | $2,818.38 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $4,570.88
| Professional | | $2,187.76 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $3,548.13 / $6,025.60
| Professional | | $331.13 | $3,548.13 | $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
- $2,290.87 / $3,548.13 / $6,025.60
| Professional | | $2,290.87 | $3,548.13 | $6,025.60 |