- 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
- $707.95 / $812.83 / $2,187.76
| Professional | | $707.95 | $812.83 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,348.96
| Professional | | $707.95 | $812.83 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $1,659.59
| Professional | | $891.25 | $1,202.26 | $1,659.59 |
- 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
- $676.08 / $954.99 / $1,737.80
| Professional | | $676.08 | $954.99 | $1,737.80 |