- 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
- $1,174.90 / $1,412.54 / $3,715.35
| Professional | | $1,174.90 | $1,412.54 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $2,089.30
| Professional | | $933.25 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,584.89 / $2,511.89
| Professional | | $181.97 | $1,584.89 | $2,511.89 |
- 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
- $1,096.48 / $1,513.56 / $2,570.40
| Professional | | $1,096.48 | $1,513.56 | $2,570.40 |