- 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
- $588.84 / $1,096.48 / $2,818.38
| Professional | | $588.84 | $1,096.48 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,737.80
| Professional | | $741.31 | $870.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $1,905.46
| Professional | | $912.01 | $1,348.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $13,489.63
| Facility | | $3,715.35 | $7,762.47 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $1,949.84
| Professional | | $724.44 | $1,288.25 | $1,949.84 |