- 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 / $1,380.38 / $3,090.30
| Professional | | $1,071.52 | $1,380.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,862.09
| Professional | | $851.14 | $1,122.02 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,380.38 / $2,238.72
| Professional | | $181.97 | $1,380.38 | $2,238.72 |
- 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
- $977.24 / $1,348.96 / $2,137.96
| Professional | | $977.24 | $1,348.96 | $2,137.96 |