- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $4,073.80
| Professional | | $1,023.29 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,691.53
| Professional | | $1,096.48 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,778.28 / $2,951.21
| Professional | | $537.03 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $3,019.95
| Professional | | $1,258.93 | $1,737.80 | $3,019.95 |