- 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
- $812.83 / $933.25 / $2,511.89
| Professional | | $812.83 | $933.25 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,584.89
| Professional | | $794.33 | $933.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,905.46
| Professional | | $1,023.29 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,995.26
| Professional | | $794.33 | $1,122.02 | $1,995.26 |