- 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
- $1,698.24 / $2,089.30 / $5,495.41
| Professional | | $1,698.24 | $2,089.30 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $3,090.30
| Professional | | $1,380.38 | $1,819.70 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $2,344.23 / $3,715.35
| Professional | | $208.93 | $2,344.23 | $3,715.35 |
- 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
- $1,621.81 / $2,290.87 / $3,801.89
| Professional | | $1,621.81 | $2,290.87 | $3,801.89 |