- 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
- $954.99 / $1,258.93 / $3,090.30
| Professional | | $954.99 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,698.24
| Professional | | $776.25 | $1,023.29 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,318.26 / $2,089.30
| Professional | | $208.93 | $1,318.26 | $2,089.30 |
- 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
- $891.25 / $1,258.93 / $1,949.84
| Professional | | $891.25 | $1,258.93 | $1,949.84 |