- 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 / $1,445.44 / $3,630.78
| Professional | | $1,174.90 | $1,445.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,398.83
| Professional | | $1,174.90 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $1,737.80 / $3,162.28
| Professional | | $331.13 | $1,737.80 | $3,162.28 |
- 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
- $1,258.93 / $1,819.70 / $3,162.28
| Professional | | $1,258.93 | $1,819.70 | $3,162.28 |