- 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
- $831.76 / $1,548.82 / $3,630.78
| Professional | | $831.76 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $2,187.76
| Professional | | $1,047.13 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,691.53
| Professional | | $1,288.25 | $1,659.59 | $2,691.53 |
- 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
- $1,202.26 / $1,659.59 / $2,754.23
| Professional | | $1,202.26 | $1,659.59 | $2,754.23 |