- 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
- $1,737.80 / $2,137.96 / $3,981.07
| Professional | | $1,737.80 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $3,890.45
| Professional | | $1,949.84 | $2,630.27 | $3,890.45 |
- 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
- $616.60 / $2,570.40 / $5,011.87
| Professional | | $616.60 | $2,570.40 | $5,011.87 |
- 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
- $1,698.24 / $2,344.23 / $4,365.16
| Professional | | $1,698.24 | $2,344.23 | $4,365.16 |