- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $4,073.80
| Facility | | $3,630.78 | $3,630.78 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $602.56 / $1,778.28
| Facility | | $323.59 | $602.56 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $2,344.23
| Professional | | $316.23 | $446.68 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $436.52 / $467.74
| Facility | | $426.58 | $436.52 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $416.87 / $660.69
| Professional | | $316.23 | $416.87 | $660.69 |