- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,786.30
| Facility | | $3,981.07 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $3,630.78
| Professional | | $1,047.13 | $1,412.54 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $2,454.71
| Professional | | $776.25 | $912.01 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,187.76
| Professional | | $812.83 | $1,230.27 | $2,187.76 |
- 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
- $758.58 / $1,380.38 / $1,778.28
| Professional | | $758.58 | $1,380.38 | $1,778.28 |