- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $794.33 / $1,995.26
| Professional | | $630.96 | $794.33 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $758.58 / $1,318.26
| Professional | | $645.65 | $758.58 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,584.89
| Professional | | $851.14 | $1,071.52 | $1,584.89 |
- 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
- $660.69 / $912.01 / $1,659.59
| Professional | | $660.69 | $912.01 | $1,659.59 |