- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $3,548.13
| Professional | | $954.99 | $1,380.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $2,137.96
| Professional | | $933.25 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,548.82 / $2,570.40
| Professional | | $151.36 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,691.53
| Professional | | $1,122.02 | $1,584.89 | $2,691.53 |