- 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
- $724.44 / $1,258.93 / $3,162.28
| Professional | | $724.44 | $1,258.93 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $1,905.46
| Professional | | $831.76 | $977.24 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $2,290.87
| Professional | | $1,047.13 | $1,513.56 | $2,290.87 |
- 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
- $1,071.52 / $1,412.54 / $2,238.72
| Professional | | $1,071.52 | $1,412.54 | $2,238.72 |