- 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
- $794.33 / $954.99 / $2,344.23
| Professional | | $794.33 | $954.99 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,380.38
| Professional | | $630.96 | $851.14 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,096.48 / $1,698.24
| Professional | | $181.97 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $1,584.89
| Professional | | $724.44 | $1,023.29 | $1,584.89 |