- 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
- $1,995.26 / $2,818.38 / $6,456.54
| Professional | | $1,995.26 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,454.71 / $4,466.84
| Professional | | $2,187.76 | $2,454.71 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,786.30
| Professional | | $2,570.40 | $3,235.94 | $4,786.30 |
- 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
- $1,995.26 / $2,818.38 / $5,128.61
| Professional | | $1,995.26 | $2,818.38 | $5,128.61 |