- 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
- $1,659.59 / $1,949.84 / $4,365.16
| Professional | | $1,659.59 | $1,949.84 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $3,235.94
| Professional | | $1,348.96 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,238.72 / $3,630.78
| Professional | | $331.13 | $2,238.72 | $3,630.78 |
- 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 / $2,137.96 / $3,630.78
| Professional | | $1,479.11 | $2,137.96 | $3,630.78 |