- 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
- $707.95 / $1,348.96 / $3,090.30
| Professional | | $707.95 | $1,348.96 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $1,905.46
| Professional | | $891.25 | $1,047.13 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $2,290.87
| Professional | | $870.96 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $6,025.60
| Facility | | $1,348.96 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,412.54 / $2,344.23
| Professional | | $630.96 | $1,412.54 | $2,344.23 |