- 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
- $977.24 / $1,202.26 / $2,630.27
| Professional | | $977.24 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,905.46
| Professional | | $794.33 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $1,288.25 / $2,137.96
| Professional | | $331.13 | $1,288.25 | $2,137.96 |
- 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
- $831.76 / $1,258.93 / $2,137.96
| Professional | | $831.76 | $1,258.93 | $2,137.96 |