- 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
- $1,479.11 / $1,949.84 / $4,073.80
| Professional | | $1,479.11 | $1,949.84 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,884.03
| Professional | | $1,202.26 | $1,621.81 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,137.96 / $3,235.94
| Professional | | $331.13 | $2,137.96 | $3,235.94 |
- 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
- $1,380.38 / $1,905.46 / $3,311.31
| Professional | | $1,380.38 | $1,905.46 | $3,311.31 |