- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $4,897.79
| Professional | | $1,513.56 | $1,995.26 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $3,162.28
| Professional | | $1,548.82 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $4,365.16
| Professional | | $1,995.26 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $6,025.60
| Facility | | $1,380.38 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $4,365.16
| Professional | | $1,445.44 | $2,290.87 | $4,365.16 |