- 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
- $549.54 / $758.58 / $1,995.26
| Professional | | $549.54 | $758.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $758.58 / $1,230.27
| Professional | | $660.69 | $758.58 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,548.82
| Professional | | $831.76 | $1,202.26 | $1,548.82 |
- 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
- $645.65 / $933.25 / $1,621.81
| Professional | | $645.65 | $933.25 | $1,621.81 |