- 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
- $691.83 / $1,318.26 / $3,090.30
| Professional | | $691.83 | $1,318.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $1,862.09
| Professional | | $891.25 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $2,238.72
| Professional | | $1,071.52 | $1,412.54 | $2,238.72 |
- 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
- $1,023.29 / $1,380.38 / $2,290.87
| Professional | | $1,023.29 | $1,380.38 | $2,290.87 |