- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,258.93 / $4,168.69
| Professional | | $446.68 | $1,258.93 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $831.76 / $2,137.96
| Professional | | $354.81 | $831.76 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $1,122.02 / $4,073.80
| Professional | | $309.03 | $1,122.02 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $18,620.87
| Facility | | $3,715.35 | $7,762.47 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,412.54 / $3,630.78
| Professional | | $489.78 | $1,412.54 | $3,630.78 |