- 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
- $1,348.96 / $1,584.89 / $2,951.21
| Professional | | $1,348.96 | $1,584.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,778.28 / $2,884.03
| Professional | | $1,380.38 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $3,715.35
| Professional | | $1,230.27 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,238.72 / $6,606.93
| Facility | | $575.44 | $2,238.72 | $6,606.93 |
- 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 |