- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.06 / $1,453.06 / $3,736.44
| Facility | | $1,453.06 | $1,453.06 | $3,736.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.06 / $1,453.06 / $1,951.25
| Professional | | $1,453.06 | $1,453.06 | $1,951.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,450.91 / $4,182.74 / $4,693.89
| Professional | | $3,450.91 | $4,182.74 | $4,693.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,408.92 / $3,029.05
| Professional | | $2,385.08 | $2,408.92 | $3,029.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.06 / $2,470.19 / $9,860.04
| Facility | | $1,453.06 | $2,470.19 | $9,860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $2,075.80 / $3,528.86
| Professional | | $871.84 | $2,075.80 | $3,528.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,058.66 / $3,009.91
| Professional | | $871.84 | $1,058.66 | $3,009.91 |