- 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
- $933.25 / $1,148.15 / $2,884.03
| Professional | | $933.25 | $1,148.15 | $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
- $181.97 / $1,230.27 / $1,949.84
| Professional | | $181.97 | $1,230.27 | $1,949.84 |
- 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 / $1,819.70
| Professional | | $851.14 | $1,202.26 | $1,819.70 |