- 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
- $977.24 / $1,380.38 / $3,548.13
| Professional | | $977.24 | $1,380.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $2,187.76
| Professional | | $954.99 | $1,258.93 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,621.81 / $2,691.53
| Professional | | $181.97 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $2,754.23
| Professional | | $1,071.52 | $1,621.81 | $2,754.23 |