- 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 / $1,621.81 / $3,801.89
| Professional | | $1,412.54 | $1,621.81 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,754.23
| Professional | | $1,348.96 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,041.74 / $3,548.13
| Professional | | $331.13 | $2,041.74 | $3,548.13 |
- 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
- $1,479.11 / $2,041.74 / $3,630.78
| Professional | | $1,479.11 | $2,041.74 | $3,630.78 |