- 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
- $1,258.93 / $1,737.80 / $2,818.38
| Professional | | $1,258.93 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $2,754.23
| Professional | | $1,288.25 | $1,698.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,137.96 / $3,548.13
| Professional | | $181.97 | $2,137.96 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,290.87 / $3,715.35
| Professional | | $1,513.56 | $2,290.87 | $3,715.35 |