- 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
- $1,174.90 / $2,187.76 / $5,754.40
| Professional | | $1,174.90 | $2,187.76 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,884.03
| Professional | | $1,479.11 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,691.53 / $3,801.89
| Professional | | $1,862.09 | $2,691.53 | $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
- $1,905.46 / $2,570.40 / $3,981.07
| Professional | | $1,905.46 | $2,570.40 | $3,981.07 |