- 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
- $575.44 / $691.83 / $1,819.70
| Professional | | $575.44 | $691.83 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $1,122.02
| Professional | | $588.84 | $691.83 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $1,412.54
| Professional | | $776.25 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,244.36 / $13,182.57
| Facility | | $3,235.94 | $7,244.36 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $851.14 / $1,513.56
| Professional | | $588.84 | $851.14 | $1,513.56 |