- 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
- $954.99 / $1,513.56 / $3,801.89
| Professional | | $954.99 | $1,513.56 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $2,344.23
| Professional | | $1,047.13 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,949.84 / $2,951.21
| Professional | | $363.08 | $1,949.84 | $2,951.21 |
- 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
- $1,258.93 / $2,041.74 / $3,019.95
| Professional | | $1,258.93 | $2,041.74 | $3,019.95 |