- 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
- $1,122.02 / $1,412.54 / $3,548.13
| Professional | | $1,122.02 | $1,412.54 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $1,995.26
| Professional | | $891.25 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,548.82 / $2,454.71
| Professional | | $208.93 | $1,548.82 | $2,454.71 |
- 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
- $1,047.13 / $1,479.11 / $2,238.72
| Professional | | $1,047.13 | $1,479.11 | $2,238.72 |