- 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
- $1,412.54 / $1,778.28 / $4,570.88
| Professional | | $1,412.54 | $1,778.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $2,570.40
| Professional | | $1,148.15 | $1,513.56 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,949.84 / $3,090.30
| Professional | | $208.93 | $1,949.84 | $3,090.30 |
- 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
- $1,348.96 / $1,905.46 / $2,884.03
| Professional | | $1,348.96 | $1,905.46 | $2,884.03 |