- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,705.55 / $2,419.92 / $5,821.46
| Facility | | $1,705.55 | $2,419.92 | $5,821.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.47 / $1,906.61 / $2,998.60
| Professional | | $1,267.47 | $1,906.61 | $2,998.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,387.20 / $2,212.39 / $4,583.83
| Facility | | $1,387.20 | $2,212.39 | $4,583.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.87 / $1,615.53 / $2,749.89
| Professional | | $1,002.87 | $1,615.53 | $2,749.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.96 / $960.57 / $1,692.02
| Facility | | $833.96 | $960.57 | $1,692.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.00 / $4,246.00 / $4,246.00
| Professional | | $1,238.00 | $4,246.00 | $4,246.00 |