- 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
- $851.14 / $1,202.26 / $2,884.03
| Professional | | $851.14 | $1,202.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $1,949.84
| Professional | | $891.25 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $2,137.96
| Professional | | $1,096.48 | $1,621.81 | $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
- $891.25 / $1,288.25 / $2,187.76
| Professional | | $891.25 | $1,288.25 | $2,187.76 |