- 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
- $776.25 / $933.25 / $2,570.40
| Professional | | $776.25 | $933.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $977.24 / $1,584.89
| Professional | | $831.76 | $977.24 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $1,819.70
| Professional | | $1,071.52 | $1,258.93 | $1,819.70 |
- 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
- $707.95 / $1,096.48 / $2,137.96
| Professional | | $707.95 | $1,096.48 | $2,137.96 |