- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $5,888.44
| Professional | | $1,659.59 | $2,344.23 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $3,715.35
| Professional | | $1,584.89 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,454.71 / $4,466.84
| Professional | | $181.97 | $2,454.71 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,630.27 / $4,677.35
| Professional | | $1,584.89 | $2,630.27 | $4,677.35 |