- 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
- $1,047.13 / $2,238.72 / $5,128.61
| Professional | | $1,047.13 | $2,238.72 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $3,019.95
| Professional | | $1,479.11 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,801.89
| Professional | | $1,819.70 | $2,454.71 | $3,801.89 |
- 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
- $1,318.26 / $2,344.23 / $3,890.45
| Professional | | $1,318.26 | $2,344.23 | $3,890.45 |