- 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
- $645.65 / $758.58 / $1,995.26
| Professional | | $645.65 | $758.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $707.95 / $1,412.54
| Professional | | $630.96 | $707.95 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,513.56
| Professional | | $794.33 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,762.47 / $15,135.61
| Facility | | $3,715.35 | $7,762.47 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,548.82
| Professional | | $645.65 | $977.24 | $1,548.82 |