- 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
- $812.83 / $870.96 / $2,691.53
| Professional | | $812.83 | $870.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $933.25 / $1,621.81
| Professional | | $691.83 | $933.25 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,174.90 / $1,949.84
| Professional | | $151.36 | $1,174.90 | $1,949.84 |
- 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
- $831.76 / $1,174.90 / $1,862.09
| Professional | | $831.76 | $1,174.90 | $1,862.09 |