- 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
- $660.69 / $1,174.90 / $1,513.56
| Professional | | $660.69 | $1,174.90 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,659.59
| Professional | | $794.33 | $933.25 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $2,089.30
| Professional | | $954.99 | $1,479.11 | $2,089.30 |
- 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 / $2,137.96
| Professional | | $1,023.29 | $1,380.38 | $2,137.96 |