- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,016.76 / $3,016.76 / $3,016.76
| Facility | | $3,016.76 | $3,016.76 | $3,016.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.51 / $966.64 / $1,379.82
| Professional | | $809.51 | $966.64 | $1,379.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.64 / $1,354.59 / $1,891.68
| Professional | | $1,067.64 | $1,354.59 | $1,891.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.88 / $1,625.72 / $2,982.28
| Professional | | $1,078.88 | $1,625.72 | $2,982.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.24 / $1,921.86 / $3,954.55
| Professional | | $1,281.24 | $1,921.86 | $3,954.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.00 / $1,406.28 / $2,526.86
| Professional | | $1,014.00 | $1,406.28 | $2,526.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.32 / $792.35 / $1,008.45
| Professional | | $720.32 | $792.35 | $1,008.45 |