- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,071.52 / $5,495.41
| Professional | | $954.99 | $1,071.52 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $1,819.70
| Professional | | $870.96 | $1,174.90 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,187.76
| Professional | | $1,288.25 | $1,659.59 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,290.87
| Professional | | $870.96 | $1,318.26 | $2,290.87 |