- 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
- $870.96 / $1,258.93 / $3,162.28
| Professional | | $870.96 | $1,258.93 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,995.26
| Professional | | $851.14 | $1,122.02 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,348.96 / $2,398.83
| Professional | | $363.08 | $1,348.96 | $2,398.83 |
- 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
- $933.25 / $1,412.54 / $2,511.89
| Professional | | $933.25 | $1,412.54 | $2,511.89 |