- 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
- $1,445.44 / $2,454.71 / $3,715.35
| Professional | | $1,445.44 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,801.89
| Professional | | $1,862.09 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,467.37 / $5,128.61
| Professional | | $1,862.09 | $3,467.37 | $5,128.61 |
- 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
- $1,445.44 / $2,041.74 / $4,897.79
| Professional | | $1,445.44 | $2,041.74 | $4,897.79 |