- 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
- $1,202.26 / $1,513.56 / $3,890.45
| Professional | | $1,202.26 | $1,513.56 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $2,137.96
| Professional | | $977.24 | $1,288.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,584.89 / $2,630.27
| Professional | | $208.93 | $1,584.89 | $2,630.27 |
- 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
- $1,122.02 / $1,584.89 / $2,398.83
| Professional | | $1,122.02 | $1,584.89 | $2,398.83 |