- 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
- $1,258.93 / $1,698.24 / $3,388.44
| Professional | | $1,258.93 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,238.72
| Professional | | $1,023.29 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,584.89 / $2,691.53
| Professional | | $208.93 | $1,584.89 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $7,762.47 / $19,054.61
| Facility | | $4,466.84 | $7,762.47 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $2,630.27
| Professional | | $1,122.02 | $1,659.59 | $2,630.27 |