- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $2,951.21 / $2,951.21
| Professional | | $524.81 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $288.40 / $346.74
| Professional | | $44.67 | $288.40 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $3,090.30
| Facility | | $831.76 | $2,951.21 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $478.63 / $588.84
| Professional | | $309.03 | $478.63 | $588.84 |