- 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
- $1,096.48 / $1,659.59 / $4,265.80
| Professional | | $1,096.48 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,570.40
| Professional | | $1,096.48 | $1,445.44 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,737.80 / $3,090.30
| Professional | | $363.08 | $1,737.80 | $3,090.30 |
- 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
- $1,348.96 / $1,819.70 / $3,235.94
| Professional | | $1,348.96 | $1,819.70 | $3,235.94 |