- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,124.14 / $3,603.70 / $5,568.43
| Facility | | $2,124.14 | $3,603.70 | $5,568.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.94 / $2,179.94 / $2,179.94
| Professional | | $2,179.94 | $2,179.94 | $2,179.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.66 / $2,856.60 / $3,954.15
| Facility | | $1,541.66 | $2,856.60 | $3,954.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.60 / $1,743.95 / $2,346.16
| Facility | | $1,099.60 | $1,743.95 | $2,346.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.32 / $701.88 / $8,684.87
| Professional | | $491.32 | $701.88 | $8,684.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.32 / $701.88 / $1,754.70
| Professional | | $491.32 | $701.88 | $1,754.70 |