- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,943.28 / $7,943.28
| Facility | | $3,981.07 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $3,548.13
| Professional | | $933.25 | $1,380.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $2,137.96
| Professional | | $912.01 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,445.44 / $2,630.27
| Professional | | $363.08 | $1,445.44 | $2,630.27 |
- 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
- $1,122.02 / $1,548.82 / $2,691.53
| Professional | | $1,122.02 | $1,548.82 | $2,691.53 |