- 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
- $1,288.25 / $1,621.81 / $3,715.35
| Professional | | $1,288.25 | $1,621.81 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,344.23
| Professional | | $1,023.29 | $1,380.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,584.89 / $2,818.38
| Professional | | $181.97 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $15,135.61
| Facility | | $3,235.94 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,691.53
| Professional | | $1,202.26 | $1,778.28 | $2,691.53 |