- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,553.39 / $1,553.39 / $3,994.43
| Facility | | $1,553.39 | $1,553.39 | $3,994.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.39 / $1,553.39 / $2,085.98
| Professional | | $1,553.39 | $1,553.39 | $2,085.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,689.19 / $4,471.55 / $5,018.01
| Professional | | $3,689.19 | $4,471.55 | $5,018.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,575.36 / $3,238.32
| Professional | | $2,549.86 | $2,575.36 | $3,238.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,553.39 / $2,640.76 / $10,540.87
| Facility | | $1,553.39 | $2,640.76 | $10,540.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $2,219.13 / $3,772.52
| Professional | | $932.03 | $2,219.13 | $3,772.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,131.76 / $3,106.78
| Professional | | $932.03 | $1,131.76 | $3,106.78 |