- 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 / $4,073.80
| Professional | | $1,584.89 | $1,905.46 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $3,090.30
| Professional | | $1,288.25 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,187.76 / $3,467.37
| Professional | | $331.13 | $2,187.76 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- 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 |