- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $6,165.95
| Professional | | $1,862.09 | $2,398.83 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $3,715.35
| Professional | | $1,995.26 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $4,570.88
| Professional | | $2,344.23 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $5,011.87
| Professional | | $1,819.70 | $2,691.53 | $5,011.87 |