- 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
- $3,715.35 / $7,762.47 / $10,471.29
| Professional | | $3,715.35 | $7,762.47 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $3,548.13 / $7,943.28
| Professional | | $208.93 | $3,548.13 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,630.78 / $7,244.36
| Facility | | $1,659.59 | $3,630.78 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,370.32 / $8,128.31
| Professional | | $3,388.44 | $5,370.32 | $8,128.31 |