- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,621.81 / $3,235.94
| Professional | | $457.09 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,096.48 / $2,454.71
| Professional | | $426.58 | $1,096.48 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $954.99 / $3,890.45
| Professional | | $199.53 | $954.99 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,548.82 / $3,090.30
| Professional | | $478.63 | $1,548.82 | $3,090.30 |