- 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
- $1,096.48 / $1,380.38 / $3,467.37
| Professional | | $1,096.48 | $1,380.38 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $1,949.84
| Professional | | $891.25 | $1,174.90 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,513.56 / $2,398.83
| Professional | | $181.97 | $1,513.56 | $2,398.83 |
- 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
- $1,023.29 / $1,513.56 / $2,187.76
| Professional | | $1,023.29 | $1,513.56 | $2,187.76 |