- 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
- $912.01 / $1,148.15 / $2,951.21
| Professional | | $912.01 | $1,148.15 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $1,621.81
| Professional | | $741.31 | $977.24 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,230.27 / $1,995.26
| Professional | | $181.97 | $1,230.27 | $1,995.26 |
- 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
- $851.14 / $1,202.26 / $1,862.09
| Professional | | $851.14 | $1,202.26 | $1,862.09 |