- 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
- $1,071.52 / $1,548.82 / $3,890.45
| Professional | | $1,071.52 | $1,548.82 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,454.71
| Professional | | $1,096.48 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,584.89 / $3,019.95
| Professional | | $181.97 | $1,584.89 | $3,019.95 |
- 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
- $1,174.90 / $1,778.28 / $3,090.30
| Professional | | $1,174.90 | $1,778.28 | $3,090.30 |