- 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 / $2,344.23 / $6,025.60
| Professional | | $1,548.82 | $2,344.23 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $3,630.78
| Professional | | $1,513.56 | $1,995.26 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $2,398.83 / $4,365.16
| Professional | | $446.68 | $2,398.83 | $4,365.16 |
- 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
- $1,862.09 / $2,630.27 / $4,466.84
| Professional | | $1,862.09 | $2,630.27 | $4,466.84 |