- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $13,489.63
| Facility | | $1,659.59 | $1,659.59 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,698.24 / $1,778.28
| Professional | | $1,548.82 | $1,698.24 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $8,511.38
| Facility | | $3,630.78 | $3,715.35 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,754.23
| Professional | | $933.25 | $1,318.26 | $2,754.23 |