- 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
- $630.96 / $741.31 / $1,995.26
| Professional | | $630.96 | $741.31 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $741.31 / $1,230.27
| Professional | | $630.96 | $741.31 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,548.82
| Professional | | $831.76 | $1,023.29 | $1,548.82 |
- 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
- $645.65 / $912.01 / $1,621.81
| Professional | | $645.65 | $912.01 | $1,621.81 |