- 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
- $1,819.70 / $2,238.72 / $4,897.79
| Professional | | $1,819.70 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $3,548.13
| Professional | | $1,479.11 | $1,949.84 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,570.40 / $3,981.07
| Professional | | $331.13 | $2,570.40 | $3,981.07 |
- 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
- $1,659.59 / $2,344.23 / $3,981.07
| Professional | | $1,659.59 | $2,344.23 | $3,981.07 |