- 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
- $912.01 / $977.24 / $3,019.95
| Professional | | $912.01 | $977.24 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,819.70
| Professional | | $776.25 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,288.25 / $2,137.96
| Professional | | $151.36 | $1,288.25 | $2,137.96 |
- 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
- $933.25 / $1,258.93 / $2,089.30
| Professional | | $933.25 | $1,258.93 | $2,089.30 |