- 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 / $2,041.74 / $4,570.88
| Professional | | $1,479.11 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,884.03
| Professional | | $1,513.56 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,467.37
| Professional | | $1,905.46 | $2,398.83 | $3,467.37 |
- 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
- $1,445.44 / $2,089.30 / $3,801.89
| Professional | | $1,445.44 | $2,089.30 | $3,801.89 |