- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $3,090.30
| Professional | | $1,023.29 | $1,202.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $1,905.46
| Professional | | $977.24 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $2,344.23
| Professional | | $1,288.25 | $1,513.56 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,630.27
| Professional | | $933.25 | $1,348.96 | $2,630.27 |