- 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
- $851.14 / $1,174.90 / $2,398.83
| Professional | | $851.14 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $1,548.82
| Professional | | $676.08 | $912.01 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,047.13 / $1,819.70
| Professional | | $181.97 | $1,047.13 | $1,819.70 |
- 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
- $741.31 / $1,148.15 / $1,778.28
| Professional | | $741.31 | $1,148.15 | $1,778.28 |