- 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
- $676.08 / $977.24 / $2,089.30
| Professional | | $676.08 | $977.24 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $912.01 / $1,659.59
| Professional | | $676.08 | $912.01 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $1,995.26
| Professional | | $891.25 | $1,288.25 | $1,995.26 |
- 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
- $707.95 / $1,071.52 / $1,949.84
| Professional | | $707.95 | $1,071.52 | $1,949.84 |