- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $4,365.16
| Professional | | $1,380.38 | $1,659.59 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $2,754.23
| Professional | | $1,412.54 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,311.31
| Professional | | $1,819.70 | $2,454.71 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $26,915.35
| Facility | | $4,466.84 | $8,128.31 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $3,548.13
| Professional | | $1,348.96 | $2,041.74 | $3,548.13 |