- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,737.80 / $4,466.84
| Professional | | $1,174.90 | $1,737.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $2,884.03
| Professional | | $1,318.26 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $2,238.72 / $3,715.35
| Professional | | $151.36 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $3,801.89
| Professional | | $1,318.26 | $2,238.72 | $3,801.89 |