- 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
- $1,778.28 / $2,238.72 / $5,754.40
| Professional | | $1,778.28 | $2,238.72 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $3,162.28
| Professional | | $1,412.54 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $2,344.23 / $3,890.45
| Professional | | $239.88 | $2,344.23 | $3,890.45 |
- 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
- $1,659.59 / $2,344.23 / $3,548.13
| Professional | | $1,659.59 | $2,344.23 | $3,548.13 |