- 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
- $660.69 / $758.58 / $2,041.74
| Professional | | $660.69 | $758.58 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $758.58 / $1,258.93
| Professional | | $676.08 | $758.58 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $1,548.82
| Professional | | $851.14 | $1,096.48 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $12,022.64
| Facility | | $2,818.38 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $891.25 / $1,621.81
| Professional | | $645.65 | $891.25 | $1,621.81 |