- 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
- $2,137.96 / $2,344.23 / $7,079.46
| Professional | | $2,137.96 | $2,344.23 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $4,365.16
| Professional | | $1,905.46 | $2,570.40 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $3,235.94 / $5,248.07
| Professional | | $151.36 | $3,235.94 | $5,248.07 |
- 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
- $2,137.96 / $3,090.30 / $5,128.61
| Professional | | $2,137.96 | $3,090.30 | $5,128.61 |