- 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
- $1,513.56 / $1,862.09 / $4,168.69
| Professional | | $1,513.56 | $1,862.09 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,951.21
| Professional | | $1,230.27 | $1,621.81 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,187.76 / $3,311.31
| Professional | | $331.13 | $2,187.76 | $3,311.31 |
- 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 / $1,949.84 / $3,311.31
| Professional | | $1,318.26 | $1,949.84 | $3,311.31 |