- 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
- $3,890.45 / $4,786.30 / $10,471.29
| Professional | | $3,890.45 | $4,786.30 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,168.69 / $7,585.78
| Professional | | $3,162.28 | $4,168.69 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $5,011.87 / $8,511.38
| Professional | | $446.68 | $5,011.87 | $8,511.38 |
- 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
- $3,311.31 / $5,128.61 / $8,511.38
| Professional | | $3,311.31 | $5,128.61 | $8,511.38 |