- 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
- $1,584.89 / $1,905.46 / $5,011.87
| Professional | | $1,584.89 | $1,905.46 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,659.59 / $2,818.38
| Professional | | $1,258.93 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $2,137.96 / $3,388.44
| Professional | | $208.93 | $2,137.96 | $3,388.44 |
- 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
- $1,479.11 / $2,041.74 / $3,467.37
| Professional | | $1,479.11 | $2,041.74 | $3,467.37 |