- 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
- $891.25 / $1,318.26 / $3,388.44
| Professional | | $891.25 | $1,318.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $2,041.74
| Professional | | $912.01 | $1,202.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,513.56 / $2,511.89
| Professional | | $537.03 | $1,513.56 | $2,511.89 |
- 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
- $1,071.52 / $1,479.11 / $2,630.27
| Professional | | $1,071.52 | $1,479.11 | $2,630.27 |