- 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
- $912.01 / $1,122.02 / $2,884.03
| Professional | | $912.01 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $977.24 / $1,621.81
| Professional | | $724.44 | $977.24 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,202.26 / $1,949.84
| Professional | | $208.93 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,819.70
| Professional | | $812.83 | $1,174.90 | $1,819.70 |