- 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
- $1,548.82 / $1,819.70 / $3,801.89
| Professional | | $1,548.82 | $1,819.70 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $3,019.95
| Professional | | $1,258.93 | $1,659.59 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,089.30 / $3,388.44
| Professional | | $331.13 | $2,089.30 | $3,388.44 |
- 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
- $1,348.96 / $1,995.26 / $3,388.44
| Professional | | $1,348.96 | $1,995.26 | $3,388.44 |