- 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
- $562.34 / $645.65 / $1,778.28
| Professional | | $562.34 | $645.65 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $645.65 / $1,148.15
| Professional | | $549.54 | $645.65 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $977.24 / $1,348.96
| Professional | | $707.95 | $977.24 | $1,348.96 |
- 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
- $575.44 / $812.83 / $1,412.54
| Professional | | $575.44 | $812.83 | $1,412.54 |