- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $4,466.84
| Professional | | $1,348.96 | $1,513.56 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,630.27
| Professional | | $1,174.90 | $1,584.89 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $2,041.74 / $3,235.94
| Professional | | $151.36 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $3,235.94
| Professional | | $1,202.26 | $1,862.09 | $3,235.94 |