- 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
- $1,621.81 / $1,778.28 / $5,495.41
| Professional | | $1,621.81 | $1,778.28 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $3,311.31
| Professional | | $1,412.54 | $1,905.46 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,398.83 / $3,981.07
| Professional | | $331.13 | $2,398.83 | $3,981.07 |
- 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
- $1,659.59 / $2,344.23 / $3,801.89
| Professional | | $1,659.59 | $2,344.23 | $3,801.89 |