- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $3,388.44
| Professional | | $1,023.29 | $1,318.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $1,905.46
| Professional | | $831.76 | $1,096.48 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $1,412.54 / $2,238.72
| Professional | | $89.13 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,348.96 / $2,290.87
| Professional | | $954.99 | $1,348.96 | $2,290.87 |