- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $4,786.30
| Facility | | $1,380.38 | $1,995.26 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,398.83
| Professional | | $1,023.29 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $3,715.35
| Facility | | $1,548.82 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,348.96 / $2,137.96
| Professional | | $954.99 | $1,348.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Professional | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $1,023.29
| Professional | | $524.81 | $616.60 | $1,023.29 |